Cost effective Management of Hypertension:


 Cost effective Management of Hypertension:

Professional specialty organizations demand donations in Millions for
holding conferences at Five Star Hotels and then promote expensive
brands having no regard or feelings for the poor patient’s

Prof. Emeritus Lt. Gen. Mahmud Ahmad Akhtar

As usual I have read with enormous interest ‘OFF THE RECORD’ column “Cost Effective Management of Hypertension” by Shaukat Ali Jawaid. I could not but agree more with his statements (pronouncements). Mr. Shaukat Ali Jawaid and his publications have always highlighted who so ever speaks for upholding the professional ethics for human care particularly the poor lot and who are genuinely interested in the welfare of the patients and the country by showing the mirror to all the stake holders at times at a great personal cost. For his ethical and moral values he sacrificed all the favours offered by the industry for his sterling principles unlike other publications which grabbed enormous benefits from the industry. He always supported ethical writers. He published and supported my papers on Essential Medicines- cost effective medicines/ management of diseases, prevention of diseases and promotion of health. I feel honoured he has placed my name amongst the dignitaries like Prof Khawaja Sadiq Hassan and Prof Alaf Khan and all the other ethical professionals.

Lt. Gen. (R) Mahmud Ahmad Akhtar

He has rightly said that the professional organisations have not given any importance to prevention. Prevention is not only better than cure- in fact the only cure and the true cure. Hypertension is a lifelong disease with possible devastating complications, prevention needs to be done at individual level and at mass level- community, national etc. There is dire need to prevent it by the life style therapy, detect it and its complications in the early stages and manage these. The disease is life long, therefore dire need to use cost effective medicines.

The Federal and the Provincial health departments and the medical organisations should make an all- out effort for prevention and the promotion of health. It has been done by many countries including the low middle income countries like Cuba, Sri Lanka, newly emerged Bangla Desh and many others.

Mr. Shaukat Ali Jawaid has rightly remarked repeatedly that the professional organisations taking millions from the pharma industries, spending on luxuries like extravagant dinners, musical evenings availing the luxuries of the five star hotels even at expensive hill stations thus the expenses are added to the already high drug prices. The organizations like Pakistan Hypertension League and the Pakistan Cardiac Society have become the part of the problems rather than the solution. The industry manipulates the organization for the financial gains/profits etc. by promoting their expensive brands aggressively. This must be stopped-minimum funds may be used for the continued medical education, genuine medical research and the poor patients.

There is a excellent suggestion offered by Prof Khawar Kazmi to set up Hypertension Clinics all over the country. In my article I have suggested to set up a network of coronary- care units as a part of the cardiac departments all over the country up to the level of district/tehsil to treat patients suffering from heart attacks as early treatment is important for the successful outcome. I have given the example from Rawalpindi/Islamabad to Lahore. There is not a single coronary care unit. The outcome of acute heart attacks depends upon even strokes of reaching the units within a short period. The Govt. should set up cardiac departments all over the country instead of the free standing expensive cardiac institutes. There may be one for the purpose of research. The progressive countries and also the developing countries have achieved success by adopting such policies giving priority to primary cum secondary health care followed by cost effective tertiary care.

Regarding preventive measures as said by Aristotle Diet is the best and most effective medicine. In the diet reducing excessive consumption of sodium chloride has and can achieve remarkable results. The most effective preventive measure which costs nothing, saves lives and the scarcely available resources. In UK during the last twenty years active measures have been taken to reduce the consumption of salt by creating mass awareness educating the public about the hazards of consumption of excess of salt by the health care professionals, media, celebrities and by adopting and implementing potent legislation. Due to these measures heart attacks have been reduced by 40% and strokes by 42% during this period.

Likewise in Belgium the heart attacks have decreased by eight million and strokes by six million during the last ten years. In Japan, Korea, Singapore, USA and many other countries the incidence and prevalence of hypertension and its complications have fallen considerably.

In Pakistan, the consumption of salt is very high. It is added to all types of eatables including fruits. Excess salt not only causes hypertension and its complications but is also directly injurious to heart, kidney and blood vessels. There should be an all-out massive campaign by the Govt, media, academies, NGOS/INGOS, religious leaders and health care professionals. This simple measure would produce win win situation. There are individuals who are salt sensitive- they over react to salt. Old people, those suffering from renal disorders, hypertension etc. respond over whelming to salt- once an individual start taking low salt diet, the taste buds get accustomed to low salt diet within six weeks. For taste spices etc. should mainly be used. The Nation can develop new taste.

Adopting life style measures like avoiding obesity particularly central/abdominal below 35.5 in males and less than 31.5 in females by taking diet consisting of at least five portions of vegetables/fruits(mostly veges) whole grains(complex low glycaemic index carbohydrates) pulses/legumes(beans, lentils, peas) nuts, seeds(diet should be 90% plant based) rich in fibres both soluble and insoluble, low fat dairy products, fatty fish, white meat, low saturated fats and red meat, low salt, low sugar diet, avoiding junk, deep fried and processed food, zero trans fatty acids. Adequate sleep of eight hours following the circadian rhythm, avoid tobacco in any form, pollution (including noise and light) taking regular exercise (stretching, aerobics and muscle strengthening, relaxation/meditation. More importantly five minutes exercise hourly avoiding sitting more than 40 minutes at a stretch. A five minutes of exercise every hour even walks is very useful. Abdominal fat (central obesity) is a high risk for metabolic syndrome a cluster of diabetes mellitus, hypertension, dyslipidemias leading to heart attacks, strokes, renal failures, fatty liver leading to cirrhosis and cancer. South Asians are a high risk population- abdominal girth of males should be less than 35.5 and females less than 31.5 unlike European male’s less than 40, females less than 35.5. Abdominal obesity have very high incidence and prevalence in Pakistan.

Cost Effective Drug Treatment of Hypertension

Cost effective Thiazide drugs are key to the problem of hypertension. Earlier in all the guidelines thiazides and beta blockers were recommended as the first line treatment of hypertension. Beta blockers have now been relegated if there are compelling reasons like ischaemic heart disease and cardiac dysfunction. In countries which carried out enormous treatment of hypertension at the National level, like South Africa, Cuba, Europe, Nordic etc. Thiazides were used as the first line drug.

The other groups of drugs: ACE1/A2 A, Calcium antagonists were used as the 2nd line drug. In 2015 the 8th Joint National Commission of the USA issued an evidence based guide line for the management of hypertension. The guideline is based on extensive and intensive studies of randomized controlled clinical trials, meta-analysis literature review by expert panels from the various disciplines of medical sciences.

Each of the four drug classes recommended by the panel produce comparable effects on overall mortality, cardiovascular, cerebrovascular and kidney outcomes with the exception of the heart failure outcome where thiazides had the advantage over the other groups. Improved heart failure outcome was an important finding that should be considered when selecting a drug for initial treatment of hypertension- heart failure is a serious complication of hypertension.

What Should Be The Pharmaco Economic
Treatment Strategy For Pakistan?

In my earlier articles published in 70s and 80s and in my award winning book Rational Therapeutics 1992. I had suggested that the “THIAZIDES SHOULD BE THE FIRST LINE DRUG FOR THE TREATMENT OF HYPERTENSION”. For the reason that hypertension is a lifelong disease- needs long term drug treatment therefore inexpensive. THIAZIDES ARE COST EFFECTIVE. A PATIENT TREATED WITH THIAZIDE COSTS A FRACTION OF COST OF TREATMENT THAN WITH OTHER GROUP OF DRUGS. A day’s dose of thiazide costs 35 paisas to Rs 1.50 while a day’s dose with ACE1/A2A costs Rs. 10 to Rs. 40 and Calcium Antagonists cost, the preparation Norvasc 10 mg costs approx. Rs 46 while Zopid costs Rs 2.5 approximately.

Treatment for life with thiazides would be extremely economical. Pakistan is a poor country with more than 60% people living below the poverty line i.e. cannot afford even two square meals. The Govt Health budget is meagre- one of the lowest in the world (much lower than SAARC- the drug budget is miniscule. IT IS POSSIBLE TO TREAT ALL PATIENTS OF HYPERTENSION IN PAKISTAN WITH THIAZIDE WITH GOVT/PUBLIC participation. This has been done in many countries including South Africa, Ireland etc.

In using other groups of medicines there are also cost effective preps. Where is a compelling reason to use as ACE1/A2A and Beta-blockers? The professional bodies like Pakistan Hypertension League/ Pakistan Cardiac Society should issue guide-lines based on indications and cost effectiveness. Unfortunately Pakistan is not following the WHO expert committees ‘Essential medicines (the only country in the world not to do) if it adopts it there will be generic drugs and on bulk purchase, thiazides and even other drugs prices would come down much lower. As regards the question of the quality of medicine, even the patients/docs can check the quality by monitoring the blood pressure of patients. Thiazides have proven their efficacy in Pakistan.

I have written a lot on the subject and sent communication on the subject, to the Pakistan Hypertensive League and Pakistan Cardiac Society but without any response or action. It is a sheer discourtesy, unprofessional and bad manners to not reply to senior colleagues. Unfortunately the Pakistan Hypertension League and Pakistan Cardiac Society are involved in promoting unethical, immoral, professional activity of promoting expensive brands. These professional bodies should help poor patients rather the Pharma companies.

In conclusion it is not treatment but management of hypertension which matters. The management includes life style therapy, positive attitude towards life, exercise, health friendly diet, avoidance of excess salts, healthy habits and adequate good quality sleep following the circadian rhythm taking cost effective medicines on a regular basis prescribed by a logical doctor.