Take your Medicine

We (that's royal, I guess) spend a lot of time here bashing, crushing killing and destroying the pharmaceutical industry and the FDA. We also express reservations about the medicalization of society and the disease labeling of people without symptoms or any experience of illness.

But let's keep in mind that it's a matter of appropriateness, of degree, of costs and benefits. I'm not on a jihad against pharmaceuticals or preventive medicine. Sometimes taking pills is the right thing to do, even for people who aren't sick, and a prime example is high blood pressure -- hypertension.

In Health Affairs, Cutler and colleagues analyze the costs and benefits of antihypertensive drugs, including for people whose only indication is the reading on the sphygnamometer. (Did I spell that correctly? Give me a gold star.) Abstract only available here, unless you're lucky enough to have a prescription.

Hypertension substantially raises your risk for heart disease, heart attacks, and stroke. Although some medications to reduce blood pressure were available in the 1950s, the modern "armamentarium," as the mad doctors call their available drugs became available during the 60s, 70s, and 80s. It was not until the 1970s that it became clear that prophylatic treatment of high blood pressure reduced mortality. By 2000, about two thirds of people over 40 with hypertension -- usually defined as blood pressure higher than 120/90 -- reported taking antihypertensives.

Based on what we know about the benefits of reducing blood pressure, Cutler and colleagues estimate that use of these drugs in 2001 prevented 86,000 deaths. Many of these fatal heart attacks and strokes were not just delayed, but prevented entirely, in other words the people will ultimately die of something else. What if everybody with hypertension took appropriate drugs, adhered to their prescribed regimen, and achieved normal BP? They estimate an additional 89,000 deaths would have been prevented, in other words we're only half way to where we could be. We could increase life expectancy in the U.S. by .5 years for men and .4 years for women.

Antihypertensive therapy yields something like 20 to 50 Quality Adjusted Life Years for each $1 million spent for prophylaxis; for people who are at high risk or have already had heart attacks, the benefits are much greater. That's a much better cost/benefit ratio than we readily accept for treatment of disease. Treating hypertension saves something like $15 billion a year, and we could save even more.

So why is this such a favorable situation? First of all, the important drug classes are now all available as generics. Thiazide diruetics, the first line therapy, cost only a few cents a pill. Second, these medications are very safe, as long as people work with their doctors to achieve a regimen that works without being excessive and causing fainting or other problems. Third, reducing blood pressure has a big impact on some common, serious health problems.

Why do we only get half the potential benefit? People who are uninsured are unlikely to take these drugs, which must be taken every day, till death do me and my pills part. Even people who have insurance, and get prescriptions, often stop taking them or take them erratically, because they don't feel any symptoms and it's a hassle. I have good insurance, but my monthly co-pay for my two generic hypertension meds is still $30, which might seem like too much to some people. Society would benefit substantially if these drugs were given away free to everyone who needs them.

But you don't see these drugs advertised on TV, now do you? Why is that? (Too easy for a hint.)