Self-management of Hypertension

Self-titration of Blood Pressure Medication

Medscape: Do patients need a lot of education before they start to self-monitor and self-titrate?

Prof McManus: In our study, patients had two training sessions: one at the beginning, when they were taught to measure their own BP and to work out whether they were above or below target, and a second session when they were taught to follow a titration schedule that they had agreed upon with their doctor. There were three medication changes that they could make before they needed to see their provider again. Such training obviously requires resources; however, people in higher-risk groups probably see a healthcare provider as many as four or five times a year for consultations that involve BP monitoring and medication, and these visits present potential opportunities to teach self-measurement and the sort of intervention that participants in our study did.

Medscape: The patients were already receiving good care; how did you account for the increases in thiazide diuretics and calcium channel blockers?

Prof McManus: One of the small differences in the adjusted results (not shown in the published paper) was that use of ACE inhibitors and angiotensin receptor blockers (ARBs) also increased significantly. Even so, these were increases in standard drug classes that you would expect in the intervention group over and above the control group.

Medscape: Both the usual care and intervention groups were successful in reducing BP. Isn't that one of the problems in this type of study—that the control group does as well as the intervention group, making it difficult to draw conclusions about the advantages of the intervention?

Prof McManus: You would expect a Hawthorne effect in this type of trial, where the people change their behavior simply because they are being studied, and the controls do as well as the intervention group. The control group did well because they increased their use of antihypertensives, and none of the patients had very high BP at the beginning (143-144 mm Hg baseline systolic). Inevitably with a trial like this, you identify a group of people who potentially need additional treatment, and then you have to act on that. All patients in the control group had a medication review with their physician at the beginning. For the intervention, the physician was setting up the titration schedule, and for the control group, the physician had the opportunity to start the titration process, and it appears that they probably did that for some of their patients. It is reassuring that no one came to harm from taking part in the study. You could use that as an argument to say, "Why bother?" We have shown that a group of patients who you might anticipate would have difficulty doing the intervention, because they are older, more frail, and with more comorbid conditions than the patients in our previous study, were still able to get good reductions in BP.

If we compare TASMIN-SR with the previous trial (TASMINH2), in which most of the patients had fairly uncomplicated hypertension and only a few people had coronary heart disease and other risk factors, we saw nearly double the effect size, despite starting at lower BPs. That could be an indication that they had more to gain because they already had an event, but it is probably also because we developed the intervention from the previous study, in which patients could make only two changes before needing to see their doctor again. When we looked through our results, we realized that if we gave them the option to make three changes, most patients would be able to achieve control, and from our qualitative work, we thought that they would be able to cope with that. It is reasonable to conclude that further development of the intervention, as seen in this study, has been more successful.

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