Can therapy be discontinued in well-controlled hypertension?
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
Some patients with stage 1 hypertension are well controlled, often on a single medication. After a period of years, the question arises as to whether antihypertensive therapy can be gradually diminished or even discontinued. The issue of discontinuation of therapy also arises in patients who develop symptoms related to low blood pressure.
Discontinuation of antihypertensive therapy in patients with controlled blood pressure is discussed in this topic. Withdrawal syndromes that may develop as a result of discontinuation are presented elsewhere. (See "Withdrawal syndromes with antihypertensive therapy".)
SELECTING PATIENTS FOR ANTIHYPERTENSIVE DRUG WITHDRAWAL
Among patients with mild hypertension who are well controlled for at least one year, it may be possible to gradually diminish or discontinue antihypertensive therapy [1-3].
After discontinuation of treatment, between 5 and 55 percent of patients remain normotensive for at least one to two years ; a larger fraction of patients do well with a decrease in the number and/or dose of medications taken [3,4]. In a review of published series of planned withdrawal, for example, 42 percent of selected patients with mild hypertension (140-149/90-95 mmHg) were found to remain normotensive for 12 months or longer off medication . In a more heterogeneous group of well-controlled hypertensives, only 18 percent remained normotensive after stopping therapy .
Patients who were more likely to tolerate cessation of antihypertensive therapy included those with milder hypertension, on fewer and lower doses of antihypertensive medications, and adherent to lifestyle modifications (eg, weight loss and sodium restriction). These findings suggest that full withdrawal may not be possible in patients on multiple drugs, but it may be possible to more gradually taper antihypertensive doses and agents .
- Schmieder RE, Rockstroh JK, Messerli FH. Antihypertensive therapy. To stop or not to stop? JAMA 1991; 265:1566.
- Course of blood pressure in mild hypertensives after withdrawal of long term antihypertensive treatment. Medical Research Council Working Party on Mild Hypertension. Br Med J (Clin Res Ed) 1986; 293:988.
- Freis ED, Thomas JR, Fisher SG, et al. Effects of reduction in drugs or dosage after long-term control of systemic hypertension. Am J Cardiol 1989; 63:702.
- Nelson MR, Reid CM, Krum H, et al. Short-term predictors of maintenance of normotension after withdrawal of antihypertensive drugs in the second Australian National Blood Pressure Study (ANBP2). Am J Hypertens 2003; 16:39.
- Qiu C, Winblad B, Fratiglioni L. The age-dependent relation of blood pressure to cognitive function and dementia. Lancet Neurol 2005; 4:487.
- Kennelly SP, Lawlor BA, Kenny RA. Blood pressure and the risk for dementia: a double edged sword. Ageing Res Rev 2009; 8:61.
- Moonen JE, Foster-Dingley JC, de Ruijter W, et al. Effect of Discontinuation of Antihypertensive Treatment in Elderly People on Cognitive Functioning--the DANTE Study Leiden: A Randomized Clinical Trial. JAMA Intern Med 2015; 175:1622.
- Christensen KL, Mulvany MJ. Vasodilatation, not hypotension, improves resistance vessel design during treatment of essential hypertension: a literature survey. J Hypertens 2001; 19:1001.
- Hartley RM, Velez R, Morris RW, et al. Confirming the diagnosis of mild hypertension. Br Med J (Clin Res Ed) 1983; 286:287.
- Langford HG, Blaufox MD, Oberman A, et al. Dietary therapy slows the return of hypertension after stopping prolonged medication. JAMA 1985; 253:657.
- Stamler R, Stamler J, Grimm R, et al. Nutritional therapy for high blood pressure. Final report of a four-year randomized controlled trial--the Hypertension Control Program. JAMA 1987; 257:1484.
- Nelson M, Reid C, Krum H, McNeil J. A systematic review of predictors of maintenance of normotension after withdrawal of antihypertensive drugs. Am J Hypertens 2001; 14:98.
- Appel LJ, Espeland MA, Easter L, et al. Effects of reduced sodium intake on hypertension control in older individuals: results from the Trial of Nonpharmacologic Interventions in the Elderly (TONE). Arch Intern Med 2001; 161:685.
- Finnerty FA Jr. Stepped-down therapy versus intermittent therapy in systemic hypertension. Am J Cardiol 1990; 66:1373.
- Carlsen JE, Køber L, Torp-Pedersen C, Johansen P. Relation between dose of bendrofluazide, antihypertensive effect, and adverse biochemical effects. BMJ 1990; 300:975.
- Johnston GD, Wilson R, McDermott BJ, et al. Low-dose cyclopenthiazide in the treatment of hypertension: a one-year community-based study. Q J Med 1991; 78:135.
- Houston MC. Abrupt cessation of treatment in hypertension: consideration of clinical features, mechanisms, prevention and management of the discontinuation syndrome. Am Heart J 1981; 102:415.