Predictors and mediators of successful long-term withdrawal from antihypertensive medications. TONE Cooperative Research Group. Trial of Nonpharmacologic Interventions in the Elderly.
BACKGROUND
National guidelines recommend consideration of step down or withdrawal of medication in patients with well-controlled hypertension, but knowledge of factors that predict or mediate success in achieving this goal is limited.


OBJECTIVE
To identify patient characteristics associated with success in controlling blood pressure (BP) after withdrawal of antihypertensive medication.


METHODS
The Trial of Nonpharmacologic Interventions in the Elderly tested whether lifestyle interventions designed to promote weight loss or a reduced intake of sodium, alone or in combination, provided satisfactory BP control among elderly patients (aged 60-80 years) with hypertension after withdrawal from antihypertensive drug therapy. Participants were observed for 15 to 36 months after attempted drug withdrawal.


METHODS
Trial end points were defined by (1) a sustained BP of 150/90 mm Hg or higher, (2) a clinical cardiovascular event, or (3) a decision by participants or their personal physicians to resume BP medication.


RESULTS
Proportional hazards regression analyses indicated that the hazard (+/- SE) of experiencing an end point among persons assigned to active interventions was 75% +/- 9% (weight loss), 68% +/- 7% (sodium reduction), and 55% +/- 7% (combined weight loss/sodium reduction) that of the hazard for those assigned to usual care. Lower baseline systolic BP (P < .001), fewer years since diagnosis of hypertension (P < .001), fewer years of antihypertensive treatment (P < .001), and no history of cardiovascular disease (P = .01) were important predictors of maintaining successful nonpharmacological BP control throughout follow-up, based on logistic regression analysis. Age, ethnicity, baseline level of physical activity baseline weight, medication class, smoking status, and alcohol intake were not statistically significant predictors. During follow-up, the extent of weight loss (P = .001) and urinary sodium excretion (P = .04) were associated with a reduction in the risk of trial end points in a graded fashion.


CONCLUSIONS
Withdrawal from antihypertensive medication is most likely to be successful in patients with well-controlled hypertension who have been recently (within 5 years) diagnosed or treated, and who adhere to life-style interventions involving weight loss and sodium reduction. More than 80% of these patients may have success in medication withdrawal for longer than 1 year.
Espeland
M A
MA
Department of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA. mespelan@wfubms.edu
Whelton
P K
PK
Kostis
J B
JB
Bahnson
J L
JL
Ettinger
W H
WH
Cutler
J A
JA
Appel
L J
LJ
Kumanyika
S
S
Farmer
D
D
Elam
J
J
Wilson
A C
AC
Applegate
W B
WB
D000368:Aged; D000369:Aged, 80 and over; D000428:Alcohol Drinking; D000959:Antihypertensive Agents / Q000008:administration & dosage*; D004334:Drug Administration Schedule; D015444:Exercise; D005260:Female; D006801:Humans; D008019:Life Style; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D012907:Smoking; D012982:Sodium, Dietary / Q000008:administration & dosage; D013997:Time Factors; D015431:Weight Loss
D000959:Antihypertensive Agents; D012982:Sodium, Dietary