From the Journals

Individual pediatric hypertension trials support personalized care



The preferred medication in children with hypertension varied among three common medications in n-of-1 studies with repeated ambulatory blood pressure monitoring that allowed for individualized treatment plans.

Child receiving blood pressure examination. Purestock/Thinkstock

“In usual care, the choice of specific antihypertensive regimen is based on physician preference with little or no systematic assessment of treatment benefits and hazards,” wrote Joyce P. Samuel, MD, of the University of Texas Health Science Center, Houston, and her colleagues.

In a study published in Pediatrics, the researchers assessed 32 hypertensive children who participated in n-of-1 studies at a single center. The children underwent repeated ambulatory blood pressure monitoring (APBM) to compare the effects of three medications: lisinopril, amlodipine, and hydrochlorothiazide. The children were at least 9 years old, and their primary referring physician had recommended antihypertensive treatment.

The preferred medication was defined as the one that yielded both a normal ambulatory blood pressure and the greatest reduction in average systolic blood pressure when awake for two treatment periods with no unacceptable side effects. If more than one medication met these criteria, the one with the least side effects was chosen.

Overall, the preferred medication was lisinopril for 16 patients (49%), amlodipine for 8 patients (24%), and hydrochlorothiazide for 4 patients (12%); 4 patients remained uncontrolled on monotherapy.

Each of the three medications was taken for 2 weeks, and patients were assessed with a 24-hour ABPM and a side-effect questionnaire during the final 24 hours of each treatment. A total of 27 patients reported at least one side effect during the study. Unacceptable side effects were most frequent on hydrochlorothiazide (25%), compared with 16% for lisinopril and 13% for amlodipine. None of the patients experienced hypertensive crisis, hypotension, hyperkalemia, or an increase in serum creatinine levels of more than 20% from baseline.

No single medication was preferred for at least 80% of the patients. “Within-patient variation in BP (blood pressure) response was considerable because the best-performing medication decreased the BP by about 12 mm Hg more than the worst-performing medication,” the researchers wrote.

The findings were limited by the possibility that a 2-week trial might be insufficient to evaluate medication effects, and more research is needed to refine the methods of the trials and the generalizability of the n-of-1 approach, the researchers noted. However, “this individualized approach to antihypertensive medication selection holds potential value by involving patients in their own care and facilitating informed treatment decisions,” they said.

“A randomized trial in which researchers compare usual care to routine use of n-of-1 trials with ABPM is needed to assess effects on treatment adherence, patient satisfaction, long-term BP control assessed with ABPM, and hypertensive target organ damage,” Dr. Samuel and her associates advised.

The study was supported in part by the National Center for Advancing Translational Sciences and the National Institutes of Health. The researchers had no financial conflicts to disclose.

SOURCE: Samuel JP et al. Pediatrics. 2019 Mar 6. doi: 10.1542/peds.2018-1818.

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