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Executive Summary

DIURETICS AS FIRST LINE HYPERTENSION THERAPY COULD SAVE $1 BIL. annually for every 4 mil. patients treated, William Stason, MD, Harvard School of Public Health, suggested in a presentation at the Drug Information Association's March 14-16 conference on cost-benefit analysis in Hilton Head, South Carolina. Noting that approximately $3.8 bil. is currently being spent each year on medications to treat the 40-60 mil. Americans with elevated blood pressure, Stason estimated that by starting a patient on generic diuretics, adding potassium chloride and when necessary an ACE inhibitor, the resulting average cost per year would be about $120. "For captopril [Squibb's Capoten], the average cost would be about $369," he said. "Nationally, this difference would imply a $1 bil. saving for every 4 mil. hypertensives treated." The researcher described potential cost saving treatment stategy for mild to moderate hypertension (diastolic pressure 90-104): "Start with a diuretic unless it is contraindicated. If it is clearly not tolerated, change to a beta blocker or ACE inhibitor. You may change if the quality of life is significantly reduced even though the patient can hang in there with the drug, or in the case of thiazides if the cholesterol or blood sugar increases to a level that is of concern. Finally, one changes or adds a second medication if blood pressure control is inadequate." Stason based his recommendation on the "roughly comparable" blood pressure lowering effects of currently available drug therapies -- diuretics, beta blockers, calcium channel blockers and ACE inhibitors. "In mild hypertension, thiazides and ACE inhibitors as single-drug treatment appear to control, that is lower, diastolic pressure to less than 90 mm of mercury in about 50% of patients," Stason noted. "Beta blockers and calcium channel blockers as first line therapy are somewhat less likely to be effective." The researcher emphasized that choice of therapy is therefore a tradeoff between cost and quality of life. He observed, however, that while concern about drug costs "is being talked about a lot," there has been little evidence to suggest significant progress in this area, "particularly judging from the remarkable sales success of captopril and calcium channel blockers in the last few years." Stason also indicated a need for further clinical information on the use of ACE inhibitors and calcium antagonists as first line therapy. Calling them "very exciting" and "very expensive" agents, Stason said "their appropriate role as initial therapy in hypertension has yet to be fully defined, in my view." SmithKline has sponsored several cost effectiveness studies to support the use of inexpensive diuretics as first line therapy vs. beta blockers and vasodilators.

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