Widespread use of low efficacy antihypertensive regimens for the initial treatment of hypertension among older US adults.

BACKGROUND

The choice of starting antihypertensive regimen is important because most patients remain on their initial treatment, even when their BP remains high. We examined the expected BP lowering efficacy of antihypertensive regimens initiated among US Medicare beneficiaries.

METHODS

We analyzed data on a 20% random sample of Medicare beneficiaries aged ≥65 years with a diagnosis of hypertension. The initial regimen comprised all fills within 7 days of the first antihypertensive claim in 2023 with no fills in the previous 365 days. The primary analysis was restricted to regimens including ≥1 drug class recommended in the 2025 American Heart Association/American College of Cardiology BP guideline and secondary analysis included all antihypertensive drug classes. Expected BP-lowering efficacy for each regimen was estimated using www.bpmodel.org, a model derived from 484 double-blind placebo-controlled randomized trials.

RESULTS

Among 52,031 Medicare beneficiaries initiating antihypertensive medications, 74% received monotherapy. In total, 1060 distinct drug combinations and 2836 unique drug-dose permutations were filled. The top 25 regimens accounted for 70% of initiations and conferred an average expected SBP reduction of 8 mm Hg and DBP of 4 mm Hg. When including non-guideline recommended antihypertensive regimens, the top 25 regimens were filled by 67% of patients initiating treatment, with an average expected SBP/DBP reduction of 6/3 mm Hg.

CONCLUSIONS

Most antihypertensive regimens initiated among US Medicare beneficiaries were low efficacy monotherapy. Initiating more effective antihypertensive therapy has the potential to improve BP control in the United States.