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Dr. Neutel: I think we’ve reached a crossroads in therapy with two different classes of drugs. The response rate is increased to about 75% to 80% and side the therapeutics of hypertension and it may be time to make a decision as to whether we’re treating hypereffects are lower than with moderate to large doses of single agents. Blood pressure control is achieved tension correctly. To set the stage for our discussion, I’ll summarize in a shorter period of time, patients require fewer clinic visits to achieve blood pressure control, and the some of what we’ve heard and pose some questions. We’ve been advised in the past by the Joint National cost may be less with some of the lower dose combinations than with some of the most commonly used Committee and we learn at medical school that the way to treat hypertension is with monotherapy—you monotherapies. It would appear from some of the data presented choose one drug at a low dose and increase that dose until you get blood pressure control or reach the maxiby Dr. Frishman that we can achieve many of the objectives of ideal therapy with a new b-blocker/dimum dosage. If you don’t achieve goal blood pressure, you add a second drug. There are, however, uretic combination. We are at a crossroads and should ask ourselves: Is it always correct to use monotherapy problems with monotherapy. The rationale behind this kind of approach is that as initial treatment or should we initiate therapy in many cases with low-dose combinations? if you use one drug, it’s more convenient for patients, there will be fewer side effects and, if there are adQUESTIONS AND ANSWERS verse reactions, you will know which drug is causing them. Response rates with any single class of antihyPerhaps I could start off by asking Dr. Abernethy a pertensive drug, however, are only about 45% to 55%; question. Do you decrease the duration of efficacy about half of the hypertensive population are going when you reduce the doses of the components of comto need a second drug anyway. binations? Fairly high doses of one agent are usually necessary to achieve blood pressure control. We have heard that side effects are frequently dose-dependent. There are Dr. Abernethy: Duration of action appears to be also increased dose-dependent metabolic side effects class-specific. There is a dissociation. For example, with some drugs and oftentimes increased cost. there is not a good relationship between drug concenThe speakers in this symposium have presented tration and antihypertensive effect with thiazide didata on the advantages of lower-dose combination uretics. If one assumed that one needed a long halflife thiazide-type diuretic for optimal antihypertensive effect, we’d always use chlorthalidone, but hyFrom the Orange County Heart Institute and Research Center, drochlorothiazide, which has a much shorter half-life, Orange, California (JN); Georgetown Medical Center, Washington, appears to have an equally effective antihypertensive D.C. (DRA); Yale University School of Medicine, New Haven, Connecticut (MM); Cleveland Clinic Foundation, Cleveland, Ohio effect. The same could be said of b-blockers. With the (RWG); and Albert Einstein School of Medicine, Bronx, New York calcium antagonists, the antihypertensive effect is lost (WHF) . if doses are reduced or the type of drug used has a Address correspondence and reprint requests to Marvin Moser, MD, 13 Murray Hill Rd., Scarsdale, NY 10583. short duration of action. The same is generally true

Discussion: Recent Data on the Safety and Efficacy of Newer Therapies in the Management of Hypertension