Self-titration of Antihypertensive Therapy Improves BP Control

The Telemonitoring and Self-Management in the Control Of Hypertension (TASMINH2) study was conducted in a primary-care setting and also employed telemonitoring as a "safety net."  

Dr. Richard J. McManus (Primary Care Clinical Services, University of Birmingham, UK) stated that, "We've shown for the first time on a large scale in hypertension that involving patients much more directly in their own care by adjusting their own medication following their own measurement of their BP can result in significantly better BP control that seems to be sustained and, in fact, increased as time went on in the study." 

In their paper, McManus et al explain that only one small study, in 31 individuals, has looked at self-monitoring of BP together with self-titration of therapy, and although it showed encouraging findings, it lasted only eight weeks. The addition of telemonitoring -- whereby readings made at home are relayed to a healthcare professional who can take appropriate action -- "adds a safety net by which researchers and clinicians can be reassured that patients are not ignoring very high (or low) [BP] readings," they note.

In the TASMINH2 study, patients aged 35 to 85 years, with BP greater than 140/90 mm Hg despite antihypertensive treatment, were enrolled from 24 general practices in the UK and randomized to self-management (n=234) or control (n=246). Those assigned to the intervention group were asked to attend two training sessions run by the research team to learn how to use their automated BP monitor and how to transmit BP readings to the team by means of an automated modem device.

Drug-titration schedules, consisting of two changes or increases in medication, were agreed between participants in the intervention group and their GP at a review visit after training and included the option of renal monitoring for ACE inhibitors. The doctor received no specific instruction from the research team about suitable medication changes.

Patients in the control group were asked to attend a review by their GP. No specific instructions were given about the content of this visit other than to review blood-pressure medication and, thereafter, care was at the discretion of the doctor.

In the intervention group, patients were asked to check their BP every day in the first week of each month. A traffic-light system was used by participants to code these readings as green (below target but above safety limit), amber (above target but within safety limits), or red (outside of safety limits). A month was deemed to be "above target" if the readings on four or more days were above 130/85 mm Hg for those without diabetes and 130/75 mm Hg for those with diabetes.

If the readings were above target on two consecutive months, patients were required to adjust their medications according to the prespecified titration schedules. They were asked to contact their doctor or the research team if their blood-pressure readings exceeded the safety limit of 200/100 mm Hg or if their systolic blood pressure was less than 100 mm Hg. When the patient had not contacted the research team despite blood-pressure readings that were outside the safety limits (based on telemonitored readings), the research team contacted such patients by telephone.

The primary end point of the study was change in mean systolic BP between baseline and each follow-up point (six and 12 months). The intervention resulted in substantially lower systolic blood pressure than did usual care, by 3.7 mm Hg at six months (p=0.013) and by 5.4 mm Hg (p=0.0004) at 12 months. The BP reduction was associated with greater medication adjustment in the intervention group than the control group.

This absolute reduction in BP is equivalent to a reduction in risk of stroke of more than 20% and in coronary heart disease of more than 10%, say McManus et al.

Self-management interventions that empower patients to self-titrate their own medication [are important].

Self-management and self-titration are not for everyone.

McManus mentioned that the researchers looked at a number of prespecified subgroups and found no clear differences between most of them; unfortunately, the study turned out to be insufficiently powered to detect differences. But they did see a trend toward greater reduction in systolic BP in patients with a low index of multiple deprivation (p=0.08).

McManus stressed that "not everyone is going to want to do this": of more than 7,500 participants who were initially invited to enter the study, less than 10% eventually did.

McManus RJ, Mant J, Bray EP, et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): A randomised controlled trial. The Lancet 2010; DOI:10.1016/S0140-6736(10)60964-6. Available at: http://www.thelancet.com.