Global Insight Perspective | |
Significance | IQWiG has recommended the use of diuretics as a preferred introductory monotherapy for patients newly diagnosed with hypertension. |
Implications | The recommendation is the end result of a second draft of a comparative report on hypertension drugs used to initiate treatment in new patients. The report claims that diuretics offer the best degree of efficacy when compared with beta blockers, ACE inhibitors, calcium antagonists and angiotensin II antagonists. |
Outlook | Hypertension is a large and growing healthcare problem in Germany, and increased spending on hypertension drugs will be a burden to the public healthcare system. Beyond promoting the prescription of generic blood-pressure drugs, formulating policy on the most effective and cheapest treatment class will help to reduce costs. |
Germany's Institute for Quality and Efficiency in Healthcare (IQWiG) has published the second version of a report on anti-hypertensive drugs that seeks to establish the best method of initiating treatment for high blood pressure. The report, which will be made open for public comment until 17 October, assesses the five leading types of anti-hypertension drugs on sale in Germany, and concludes that diuretics offer the highest overall level of efficacy.
IQWiG's report covers diuretics, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium antagonists and angiotensin II antagonists, assessing them not for their ability to reduce blood pressure but to prevent related complications. It is based on the findings of eight clinical trials that allow for comparisons between the five drug classes on a variety of points, including their capacity to prolong life, the prevention of heart disease, stroke or kidney damage, the effect on quality of life, side-effects, frequency of hospitalisation, and patient satisfaction with treatment. IQWiG has freely admitted that the trials it selected were more forthcoming with data on some treatments (namely diuretics and calcium antagonists) than others (particularly angiotensin II antagonists).
In spite of this, the agency has recommended that diuretics should be used as the preferred first-line treatment for patients diagnosed with hypertension. Despite the link to an increase in blood sugar for diabetic patients, diuretics were found to offer therapeutic advantages over both ACE inhibitors and calcium antagonists in reducing the risk of heart failure. IQWiG's researchers confirmed existing findings on side-effects associated with all five types of hypertension therapy, but said that patients who developed diabetes mellitus after the introduction of diuretic treatment did not see their risk of cardiovascular disease increase.
Outlook and Implications
Hypertension is a major health issue in Germany, counting for up to 26% of all mortality in the country. In addition to patients already receiving treatment for the condition, it is estimated that as many as 15 million Germans may be living with untreated hypertension. As the population ages, the number of people requiring treatment for high blood pressure is expected to rise, creating an additional burden on the already overstretched public healthcare system. While IQWiG's report has avoided including economic factors such as drug pricing, diuretics are generally a less expensive treatment option, particularly when used as a monotherapy, and this is bound to be taken into consideration once IQWiG's finalised report is submitted to the Federal Joint Committee on Healthcare (G-BA). Implicitly, the fact that IQWiG is favouring monotherapy over combination treatment with multiple drugs as the ideal starting treatment can also be viewed as a cost-conscious decision. This is despite the Institute's own estimate that half of all hypertension patients are adequately treated with a monotherapy, while the remaining half require two or sometimes three separate forms of complementary treatment.