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2026 (English) In: eClinicalMedicine, E-ISSN 2589-5370, Vol. 91, article id 103696Article in journal (Refereed) Published
Abstract [en] Background: Only half of patients appear adherent to antihypertensive treatment. If so, the effectiveness in prevention against adverse cardiovascular outcomes may depend more on a drugs' side effects than its blood pressure effects. We hypothesized that initiating treatment with a particular antihypertensive drug class will determine later persistence.
Methods: We applied a new-user trial emulation approach to multiple mandatory health-care registers in Sweden. All individuals starting antihypertensive treatment with an angiotensin receptor blocker (ARB), angiotensin converting enzyme inhibitor (ACEi), calcium channel blocker (CCB), thiazide/thiazide-like diuretic (TD), or single-pill combination of two drugs (SPC) in 2011-2018 were assessed for inclusion. Patients with prior cardiovascular disease or diabetes were excluded. Persistence was defined using dispensed prescription refills with at least 80% adherence. We applied multistate Poisson regression models adjusting for age, sex, obesity, birth country, education, income, marital status and year of initiation. The study period was January 1st 2011-December 31st 2019.
Findings: A total of 341,182 patients were included. Initiating antihypertensive treatment with an ARB was associated with a larger proportion continuing their original drug class, or indeed any antihypertensive drug class, at any time during the five years of follow-up. At three years, 44.7% (CI 43.7-45.7) of the ARB initiators were continuously persistent to their original drug class. The corresponding number if intermittent discontinuations were allowed was 81.8% (CI 80.9-82.8). Overall, if intermittent discontinuations and changes between classes were allowed, about 80% of all new users of antihypertensive drugs (regardless of class at initiation) were persistent to at least one antihypertensive drug class over 5 years.
Interpretation: Initiating treatment with an ARB is associated with the best long-term class persistence and least treatment changes. The "rule of halves" should be replaced with the insight that, after the first year, at least 4 out of 5 patients take their antihypertensive drug at least 4 out of 5 days.
Place, publisher, year, edition, pages
Elsevier, 2026
Keywords Persistence, Medication adherence, Antihypertensive agents, Register study, Hypertension, First-line, drug choice
National Category
Cardiology and Cardiovascular Disease Public Health, Global Health and Social Medicine
Identifiers urn:nbn:se:uu:diva-579200 (URN) 10.1016/j.eclinm.2025.103696 (DOI) 001677277600001 () 41625962 (PubMedID)
Funder Swedish National Infrastructure for Computing (SNIC), sens2020005Swedish National Infrastructure for Computing (SNIC), sens2020598
2026-02-162026-02-162026-02-16 Bibliographically approved