Trends in first-line monotherapy and combination therapy for hypertension in UK primary care

Debate remains about the optimal initial treatment strategy for hypertension. Most guidelines recommend first-line combination therapy for most patients. However, the UK's National Institute for Health and Care Excellence recommends first-line monotherapy for all patients. It is unknown if first-line combination therapy use is increasing despite this recommendation. This study aims to assess trends in prescriptions for first-line antihypertensive monotherapy and combination therapy in UK primary care.

Using the Clinical Practice Research Datalink, we formed a cohort of all patients newly diagnosed with hypertension between 2011 and 2019. We calculated annual proportions of patients newly prescribed first-line monotherapy and combination therapy within 3 months of diagnosis. We used Kaplan-Meier methods to estimate the median treatment persistence, and the probability of persistence at 6 months and 1 year for mono- and combination therapy.

Among 535 234 patients with hypertension, 1.7% received first-line combination therapy, while 85.6% received monotherapy. Rates of initiation varied by age and hypertension stage. Median treatment persistence was 298 (95% confidence interval [CI] 276-318) days on first-line combination therapy, compared to 398 (95% CI 394-403) days on monotherapy. At 6 months, 58.2% (95% CI 57.2%-59.3%) of combination therapy and 62.2% (95% CI 62.1%-62.4%) of monotherapy initiators remained on first-line treatment; at 1 year the numbers fell to 46.4% (95% CI 45.4%-47.6%) and 51.2% (95% CI 51.1%-51.4%), respectively.

First-line antihypertensive combination therapy remains exceedingly rare in the UK in accordance with National Institute for Health and Care Excellence guidelines, but in contrast to other international recommendations. Treatment persistence was lower on first-line combination therapy than monotherapy.