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A gloss over costs in coverage of competing blood pressure meds — but also some strengths

New class of blood pressure meds as effective as old, analysis shows

Our Review Summary

iStock_000017329510_SmallThis Washington Post story reports the findings of a study that compared the efficacy of two classes of drugs available to treat cardiovascular disease (CVD) — angiotensin converting enzyme, or ACE, inhibitors versus newer angiotensin receptor blockers, or ARBs.  It involved a meta-analysis of more than 100 earlier studies monitoring more than a quarter-million patients who were at high risk for CVD.  The results showed the two types of drugs to be equally effective with the major difference being a lower chance of side effects with the use of ARBs.

With a bit more information on harms and a better grasp of the limitations of this study, the Post’s coverage is more solid than a competing HealthDay story that was based on a news release. But the story lacks voices other than that of the study’s lead author, and it doesn’t disclose the relationships that several of the authors have with the pharmaceutical industry.


Why This Matters

For patients with high blood pressure, there are numerous studies that demonstrate medications to lower blood pressure are associated with decreased rates of heart attacks, strokes and to a lesser extent, kidney failure. Given the number of different choices available from a range of classes of medications, how do patients and doctors decide on which to use? Here the comparison is between angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs). When considering which agent to use for a given patient, a physician generally considers the relative benefits, harms and costs of the different agents, as well as any patient factors that may lead one class of agents to have particular advantages or limitations (for example, if the patient already has a high potassium level, use of either an ACEI or ARB may be problematic since they both raise potassium levels further). The current study seeks to address mainly the relative benefits of these two classes of medicines and glosses over harms and costs while not even mentioning patient-level factors. In terms of the benefits, the authors suggest that initial studies comparing ACEIs and ARBs were biased by the times in which the original studies used to justify approval were performed. Specifically, the older ACEIs studies came at a time when lifestyle and other medication options were more limited than the following decades when ARBs were studied. It is difficult to confirm or refute this assumption, but studies of these classes in a more comparable time frame would decrease bias associated with temporal trends. The current study adds evidence that these two classes are similar, but this isn’t really dramatically new information. Indeed, many guidelines suggest ACEIs or ARBs as being equivalent. The advantage of ARBs is better tolerability, as mentioned in this article, but the disadvantage remains cost. Though the article provides one line saying that with more generics available for ARBs, the cost difference has diminished, but even the cost of generics appear higher for ARBs than ACEIs. Thus, for many clinicians even an increased recognition of similar benefits may not lead to much change in practice given differences in costs


Does the story adequately discuss the costs of the intervention?


While the story could have been a bit more specific, it gets points for stating that most ACE inhibitor drugs, and many ARB drugs, are now available in generic form, which means the cost for the medications would usually be considerably less than their comparative name-brand compounds. We’ll rate this Satisfactory, but we’d add that though more ARBs are generically available, this class of medications continues to be more expensive than ACEIs. For patients struggling to meet the cost of their medications, this is a major consideration, and important information for any news story.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Not Satisfactory

The story points out that the two classes of drugs prescribed for cardiovascular disease are mostly equally effective.  It also points out that the main difference lies with the fact that patients report that ARBs are linked to fewer unpleasant side effects, compared to ACE inhibitors.  And since patients are usually kept on the drugs for long periods of time, if not indefinitely, that information is important to readers. But the story never says what outcomes exactly we’re talking about here — deaths, heart attacks, blood pressure? Nor does it say how effective these medications were at improving these outcomes — merely that they are equivalent. We think both of these issues should have been addressed in order to earn a Satisfactory rating here.

Does the story adequately explain/quantify the harms of the intervention?


The story does point to the greater occurrence of a dry cough as a result of taking ACE inhibitors compared to taking ARBs but a quick web search for both drug types shows a much larger list of possible side effects including dizziness, headaches, drowsiness, nausea, vomiting, diarrhea, low blood pressure, weakness, and skin rash, as well as increased potassium levels and possible sexual dysfunction. A similar omission is present in a HealthDay story that explained the same research.

Cough is the most common side effect of ACEI that is not generally seen with ARBs. The one other one is angioedema which is more common with ACEI. Otherwise studies show that other side effects are probably similar. This isn’t stated explicitly, but we’ll give the benefit of the doubt.

Does the story seem to grasp the quality of the evidence?


The story is accurate in characterizing this research as a “second look,” or reanalysis of more than a hundred earlier studies comparing both classes of drugs with placebos and with each other since 2000.  But while the story is cautious in saying that one class of drugs “may be as effective and safe” as the other, the headline is much more definitive, stating that “New class of blood pressure meds as effective as old, analysis shows.”  The story closes with a nod to limitations, stating that the study was limited to those who did not have heart failure, “and because it involved a retrospective analysis of trials it was unable to control for differences in the design or data gathering of the previous work.”

Does the story commit disease-mongering?


The story does not appear to commit disease-mongering.

Does the story use independent sources and identify conflicts of interest?

Not Satisfactory

The single quoted source in this story is the main author of the study and the story fails to mention that some authors have ties to major pharmaceutical firms which manufacture these kinds of drugs.  While that linkage doesn’t mean the research is definitely biased, writers should disclose that information when available.

Does the story compare the new approach with existing alternatives?


Since the story involves the comparison of two classes of drugs for treating cardiovascular disease, there are obviously treatment options available.

Does the story establish the availability of the treatment/test/product/procedure?


The story does point out that ACE inhibitor drugs have been available for decades and that ARBs have been available since the year 2000.

Does the story establish the true novelty of the approach?


The novelty here is simply that this meta-analysis is aimed at clarifying uncertainty surrounding the comparison of these two classes of drugs and their efficacy in treating cardiovascular disease.  The prevalence of this condition within the population makes it a topic of broad interest, both among the public and among the professionals who treat them.

Does the story appear to rely solely or largely on a news release?


It would be difficult to conclude that this story relied solely on a news release, given that it provided some facts not present in the NYU release.  However, the story does not stray far from the information included in the release and could benefit from additional source information and comment.  However, its similarity to the NYU news release is far less than that of a HealthDay story about the same research.

Total Score: 8 of 10 Satisfactory


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