Self-Monitoring and Titration of Meds Drops BP in TASMIN SR

Shelley Wood

August 28, 2014

OXFORD, UK — Adults with hypertension and other cardiovascular disease history or risk factors may be able to trim their blood-pressure levels by monitoring their own readings and adjusting their medications as needed[1]. Those are the findings of the small, unblinded, randomized Telemonitoring and Self-Management in Hypertension 2 (TASMIN SR) trial, conducted out of the University of Oxford.

The study, led by Dr Richard J McManus (Oxford University, UK), was published in the August 27, 2014 issue of the Journal of the American Medical Association and, according to McManus, is the first study to look at self-monitoring and self-titrating blood-pressure control since a small trial in Canada back in 1990. "But then nothing until our TASMIN H2 study and the new TASMIN SR," he said.

McManus et al report that patients randomized to self-titration were able to cut their systolic blood pressure by almost 15 mm Hg in 12 months, compared with a drop of just less than 6 mm Hg in a group managed according to usual care.

A difference of 3.4 mm Hg was also seen for diastolic BP between the two groups, such that the mean BP at study onset, 143.6/79.5 mm Hg for the group as a whole, fell to 128.6/73 mm Hg in the intervention group and 137.8/76.3 mm Hg in the usual-care group.

Results were similar across different subgroups studied, the authors write. Quality of life was no different between groups.

Adverse symptoms and drug reactions were relatively common in both groups, with no differences between the two, even for adverse symptoms that might have been related to medication use, including dizziness, impotence, and rash. "We found no increased risk above usual care," McManus stressed to heartwire . "The key prerequisite is that this is a joint approach between physician and patient—we are not recommending patients try this on their own."

For the intervention, patients randomized to "self-management" were required to do two or three training sessions in collaboration with their family physician. Training taught them how to monitor their blood pressure at home, then self-titrate their medication according to a specific, predetermined plan. Participants were required to take their blood pressure twice each morning for the first week of each month, and four or more BP readings above (or below) the target BP goal warranted a change. At that point, patients sent a form to their family physicians but were not seen again for the adjusted dose or treatment.

"This trial has shown for the first time, to our knowledge, that a group of high-risk individuals, with hypertension and significant cardiovascular comorbidity, are able to self-monitor and self-titrate antihypertensive treatment following a prespecified algorithm developed with their family physician and that in doing so they achieved a clinically significant reduction in systolic and diastolic blood pressure without an increase in adverse events," the authors write.

Next, said McManus, the group is looking into the cost-effectiveness of this approach. Then, "ideally an approach for self-monitoring in general and self-management for willing patients would be what I would like to see. Patients appear to be more able to do this than some doctors expect.”

In an accompanying editorial[2], Dr Peter M Nilsson (Skane University, Malmo, Sweden) and Dr Fredrik H Nystrom (Linköping University, Sweden) conclude that the trial supports a "bring-it-home" attitude to BP lowering, although certain questions need still to be answered. These include whether patient recruitment could be broadened to include a wider group of patients and whether the use of additional educational materials could have helped reach a broader group of patients, enabling a greater focus on how to titrate drugs or improve on home monitoring.

"In many countries, antihypertensive drugs are now available as inexpensive generic drugs. The time has come to fully use these noncostly medications and to design optimal individualized care of patients," they say.

Nilsson, also commenting on the study for heartwire by email, said he believes most patients "in a normal cognitive state can at least be offered this possibility and give it a try following instructions." One barrier to this might be the time required for health staff to provide the instructions, which "might be time-consuming for some patients." As well, Nilsson continued, "Not everybody is willing to buy a device themselves. . . . [One] good idea is that a health center could own a few devices and lend them for some period to patients."

Nilsson pointed out that healthcare providers might be more likely to support a home-monitoring/titration approach if there were financial incentives for doing so. To this point, Nystrom, also responding to heartwire by email, identified another hurdle facing wider adoption of a patient self-management approach: "The argument against [this], perhaps not said out loud, could be that visits to measure BP at the office are a way to get reimbursed for healthcare easily without too many resources spent in a commercial medical care system."

McManus reported that he has received equipment for research purposes from Omron and Lloyds Healthcare. Disclosures for the coauthors are listed in the paper. The editorialists have no disclosures.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.