◆First Choice for Drug Treatment


药物的选择是以最大限度的治疗患者，提高患者的生命质量，保证患者的幸福与安康为准绳，而非其他。

Another point of deviation from JNC 7, which the European guidelines take a firm position on, is the issue of which drugs should be assigned, or in which order, once it is determined that drug therapy is warranted. According to the Europeans, the evidence from clinical trials shows that a number of different drugs and drug classes are protective in the hypertensive patient, and therefore the obvious interpretation of the scientific data is that the largest fraction of the benefit comes from reduction of blood pressure per se. If this is the case, then the logical course should be to record the various agents that are available and leave physicians free to use whichever agent is appropriate and beneficial for the individual patient.

"We should not forget that guidelines deal with the disease and physicians deal with individual patients, and these can be quite different situations," Professor Mancia said. Thus, the ESH/ESC guidelines delineate the major indications for which a benefit has been demonstrated in clinical trials and then allow the physician to make a choice from a large number of diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers that are available and approved for use.

Another important point that should not be forgotten is that in the vast majority of the hypertensive population, good blood pressure control can be obtained only by combination treatment, Professor Mancia pointed out. This makes this insistence on the choice of first drug, as in JNC 7, somewhat obsolete, he believes, because it does not really matter which drug the patient is taking for the first 2-3 weeks if the patient will most likely be taking 2 or 3 drugs for the rest of his/her life.

Professor Mancia described the attitude of the European guidelines as a liberal one, because, he says, this is what the scientific evidence supports. This does not mean that the choice is totally blind, however; there are some criteria for selection, as detailed in the guidelines. For example, a patient's previous experience with a drug or the presence or absence of organ damage, diabetes, associated conditions, etc, must be taken into account. Some drugs have been shown to be better in some specific conditions or in some specific groups, and cost is also a factor. However --

Different Classes of Drugs

Professor Mancia pointed out that it is also important for the physician to consider adverse effects. This should be done in a very accurate manner because adverse effects are the major cause of noncompliance, a phenomenon that is disturbing to all hypertensionologists in Europe, where the number of patients with good blood pressure control is a small fraction of the hypertensive population, sometimes as low as 1 in 4. "If we want to improve this condition, then obviously physicians have to pay a great deal of attention to adverse effects, and question their patients about the presence or absence of adverse effects." Sometimes patients do not tell their doctor or they cannot interpret the adverse effects, and physicians can only identify any problems after very careful questioning, Mancia noted.

Avoid Switching

Both the European and JNC 7 guidelines discourage switching from one drug regimen to another. This practice, which used to be known as sequential monotherapy, takes a very long time and has a negative impact on the patient. In addition, the chance of achieving blood pressure control is not high. As a result, switchers are patients whose blood pressure is not controlled, and they are the ones who tend to become noncompliant.

Professor Mancia pointed out that because patients responding to drug A are not always the same as patients responding to drug B, a doctor may think that theoretically if he is persistent, he may be able to find a single antihypertensive drug that is effective. In practice, however, this does not happen, because blood pressure is a multiregulated variable and it takes several points of attack to control it and also to prevent compensating mechanisms. As a result, combination treatment is probably going to be more effective. There are instances in which sequential monotherapy is inevitable, however, Professor Mancia admitted. For example, if a drug is not effective at all, then it is useless to keep it on board; or if the patient develops a side effect, then the drug must be changed. In other words, switching cannot be prevented completely, but it should not be the regular strategy, as this is a bad policy, Professor Mancia believes.

编辑 郑麓薇