High rates of mineralocorticoid receptor antagonist discontinuation in patients with hypertension: Insights from the enlighten study

Objective:

Mineralocorticoid receptor antagonists (MRAs) are indicated for several cardiovascular (CV) conditions, including heart failure (HF) and hypertension (HTN). However, adverse drug reactions or dose-limiting side-effects may lead to discontinuation. We aimed to describe MRA discontinuation rates in patients with HTN in multiple countries.

Design and method:

Data were derived from Telotrón (Spain [ES]), IQVIA Ambulatory EMR linked with IQVIA PharMetrics® Plus closed claims data (United States [US]) and the Clinical Practice Research Datalink (CPRD) database (United Kingdom [UK] [data from additional countries will be included in the future]). Patients with a diagnosis of HTN who subsequently initiated an MRA between 2018–2023 were followed from index date, defined as the initiation of MRAs. Discontinuation was defined as a patient not having a refill/prescription beyond the last day of supply + 30 days. Median time to discontinuation and the proportion of patients discontinuing up to12 and 24 months were calculated.

Results:

In total, 15,302 patients were included across the three countries (ES: n= 1,233; US: n= 4,677; UK: n=9,391). Atindex date, one quarter (US) and one third (UK and ES) of patients had HF and 20–30% of patients had renal disease. The mean blood pressure was 132/80 mmHg in the US, 140/84 mmHg in ES and 135/79 mmHg in UK. In all three countries, patients were taking a median of two additional anti-hypertensive medications. The median (IQR) time to MRA discontinuation varied from 156 days (74, 423) in the US and 198 days (80,643) in ES to 539 days (140, 1,293) in UK. Correspondingly, the rates of MRA discontinuation at 12 and 24months were higher in the US (71% and 85%, respectively) and ES (63% and 77%, respectively), compared to UK (41% and 58%, respectively).

Conclusions:

The majority of new users of MRA with HTN discontinue treatment within one year in the US and ES, and within two years in UK. There is an urgent need for better treatment persistence to manage HTN and the risks for development of associated comorbidities.

Professor Terry McCormack is a General Practitioner and Honorary Professor of Primary Care Cardiovascular Medicine at Hull York Medical School. He is the Immediate Past President of the British and Irish Hypertension Society. For over 25 years he worked as both a GP and a Hospital Practitioner in Anaesthetics. He is particularly interested in hypertension, lipids and anticoagulation. Guideline work includes the NICE Hypertension, Perioperative Care and Venous Thromboembolism guideline committees and the AAGBI/BHS preoperative BP guideline. He is an editor of the British Journal of Cardiology and a Fellow of the European Society of Cardiology.