From: sbharris@ix.netcom.com(Steven B. Harris)
Newsgroups: sci.med.nutrition,sci.med,sci.med.pharmacy
Subject: Re: Dosing Antihypertensives (was: Determining vitamin C need)
Date: 1 Apr 1998 03:21:55 GMT

In <6fqpjk$7ac@swen.emba.uvm.edu> rlandesm@zoo.uvm.edu (Richard
Landesman) writes:

>I hope you don't use this method for determining the correct dose of
>other medications and drugs. Taking something until you get side effects
>and then tapering back is just plain stupid.



Comment:

   Though we use this method in medicine a lot <g>.  Especially back in
the old days where we were supposed to use maximum doses of one drug
(antihypertensives, say) before adding another.  And of course, though
the effects on pressure were linear with dose, the side effect profile
was shaped rather like a letter J, it it made better sense to stay at
the low end where you got more therapeutic ratio latitude.

    Some doctors even had the temerity of using combinations of
hypertensives off the bat, in order to minimize side effects.  We were
persecuted, laughed at, and made to feel as though we were poor
internists, pushers of polypharmacy, and so on.  When the combo drugs
came out, when we started with them we were looked down on as toadys of
the drug companies.  But, gosh, we said-- there is good reason to think
these low dose combos cause fewer side effects.  And the
antihypertensive effect is sometimes not merely additive, but
synergistic!   No, said our colleages, you're being stupid.  You're not
following the almighty recommendations of the JNC II committee (Joint
National Committee on hypertension), or whatever, which determines all
good clinical practice.  And we hung our heads in shame.

   Well, today it's the late 90's and by now we're up to the
recommdations of JNC VI, which came out last November 24 in the
Archives if Internal Medicine.  Hmmm.  They're recommending lose dose
combinations of antihypertensives to minimize side effects.  Lots of
important studies show it.  Gosh, you can start on these things right
from the beginning, and best of all, the rationale makes sense.  They
tell us so.  Wow, we doctors say.  Imagine that.  Progress.  Ain't
clinical medicine wonderful.

                                       Steve Harris, M.D.