NICE rewrites the rulebook over GP hypertension care
NICE has torn up the rulebook on GP treatment of hypertension and released radically revised new guidance.
The recommendations not only scrap ?-blockers as mainstream therapy but also side-line use of thiazide diuretics.
Calcium channel blockers and ACE inhibitors instead become the drugs of choice.
NICE released the guidance after reviewing 20 new trials including ASCOT. The document will be endorsed by the British Hypertension Society ending years of bitter public feuding between the organisations.
It not only represents a radical overhaul of current NICE guidance but spells the end of the society's ABCD algorithm which will become AbCd.
GPs warmly welcomed the prospect of a single unified set of guidance, but expressed alarm at the removal of diuretics as preferred treatment.
NICE has fallen into line with the BHS and recommended treatment on the basis of age and ethnicity for the first time.
Patients over 55 or black patients of any age should have a calcium channel blocker first-line, with diuretics only listed as an alternative (see panel).
In non-black patients under 55, ACE inhibitors will be the first choice under the guidance, which will be in consultation until March.
Professor Morris Brown, president of the BHS and a member of the NICE/BHS guidance development group, called it a 'new chapter' for hypertension treatment. He said a new NICE health economic analysis had found calcium channel blockers were superior to diuretics which was 'very surprising to some people'.
Professor Brown, who invented the ABCD algorithm, added: 'The concept is stronger now than it ever was. My interpretation would be big A little b big C little d.'
Dr John Ashcroft, CHD lead for Erewash PCT and a GP in Tibshelf, Derbyshire, said: 'Diuretics are still cheaper and have a better side-effect profile. My concern is how much the BHS has been swayed by its own study [ASCOT]. I worry it has pushed it too far.'
Dr Rubin Minhas, CHD lead for Medway PCT and a GP in Gillingham, Kent, called the guidance 'radical'. He added: 'Maybe NICE has gone too far.'
Under the guidance, GPs would not have to take existing patients off ?-blockers if their BP was well controlled.
But Dr Gulshan Kaul, a GP in Lichfield and practice cardiovascular lead, warned even these patients would put pressure on GPs to switch them to the newer drugs.