Updated guidance on the management of hypertension in adults in the UK offers new advice, including recommendations on the treatment of very elderly people (over 80 years old), who should be offered the same treatment as patients aged 55-80 years, while taking into account co-morbidities [1 S ]. Previous guidance has acknowledged that while elderly people may accrue benefits from lowering of blood pressure, treatment could potentially lead to more adverse events, such as syncope and falls. However, the most recent evidence challenges this position. Other useful recommendations consider the risk of adverse drug reactions in therapy; for example, the recommendation that patients should not have a combination of an angiotensin converting enzyme (ACE) inhibitor and an angiotensin II receptor antagonist to treat hypertension, based on trial evidence of increased rates of adverse events with this treatment combination. Furthermore, in view of the propensity for black people of African or Caribbean family origin to develop angioedema from ACE inhibitors, angiotensin II receptor antagonists should be used in preference to ACE inhibitors.Reviews of the pharmacotherapy of chronic pediatric hypertension [2 R ] and the management of hypertension in pregnancy [3 R ] have also been published.Nervous system The risk of falls associated with various antihypertensive drug classes has been studied in a self-controlled case series using The Health Improvement Network primary care database in the UK [4 C ]. The researchers analysed 9862 individuals over 60 years of age and estimated incidence rate ratios for falls during periods of exposure and non-exposure adjusted for age. The highest incidence rate ratio for first fall within 3 weeks of medication use was with thiazide diuretics (IRR ¼ 2.80; 95% CI ¼ 1.70, 4.57). Beta-adrenoceptor antagonists were associated with an increased incidence of falls from day 22 onwards in the first episode of medication (IRR ¼ 1.23; 95% CI ¼ 1.02, 1.48) and in subsequent episodes (IRR ¼ 1.21; 95% CI ¼ 1.02, 1.42). The implications of this analysis, given the usual limitations of prescription database research, insofar as what is recorded may not always reflect actual exposure, is that clinicians who issue prescriptions of thiazide diuretics for older people should be alert to the possibility of an increased risk of falls early in therapy.Musculoskeletal Some antihypertensive drugs are associated with changes in bone metabolism. A large prospective cohort study of hypertensive patients beginning treatment with a single antihypertensive drug has therefore been conducted using health-care utilization data to determine the risk of a typical osteoporotic fracture [5 C ]. The fracture rate in the cohort of 376 061 patients was on average 35 fractures per 1000 patient-years, but rates varied across antihypertensive drug classes. When adjusted for co-morbidities and comedications, the fracture risk was reduced for angiotensin receptor blockers (HR ¼ 0.76; 95% CI ¼ 0.68, 0.86) and thiazide diuretics (HR ¼ 0.85...
