Twelve Month Follow-Up Audit of Nigerian Hypertensives on Back Titration

Abstract

Introduction: An audit of a hypertension service in Jos, Nigeria revealed the possibility of back titration of antihypertensive therapy without untoward effect. The impact was reduction of disease economic burden. Consequently a deliberate policy of back-titration was adopted in those who have remained well controlled for >12 months. Objective: To see how low dosages could go without compromising control. Methods: All consenting hypertensive clients in this specialist hypertension clinic who had been controlled for 12 months or longer on regular follow-up(between July and September 2011); with no heart failure, renal failure, stroke or myocardial infarction (<6 months) were enrolled. Drugs were sequentially back-titrated starting with 1 drug in those on multiple drugs. Follow up continued in the usual manner, and if controlled by the next visit a further dose lowering was advised until loss of control when dose was promptly returned to the lowest maintaining control. Results: There were 41 patients initially. 2 did not follow up after the first back-titration visit leaving 39 as the subject of this analysis; 14 of whom were males. Their ages ranged from 40 to 91 years and they had been consistently controlled (BP <140/90 mmHg) for between 12 to 95 months. 18 remained normal at various stages of back-titration; in 5 (3F, 2M) all drugs had been completely withdrawn. In 21, control was lost in the course of backtitration and promptly recovered by returning to previous dose that controlled BP. Those who were successfully back-titrated to no drug were mostly on one drug at low doses. Conclusion: After a minimum of 12 months of sustained BP control, it is possible to back-titrate drug dosages in about 50% of this hypertensive cohort, a quarter of whom went completely without drugs for 1 year. The exact mechanism is unknown, but the benefit is in the psychological relief of lower pill burden and reduced cost of treatment. This observation should be extended to other cohorts to prove its applicability; advisedly only under expert care.