ARBs Show Highest Long-Term Treatment Persistence in Hypertension, suggests study

The initiation of anti-hypertensive treatment with angiotensin receptor blockers was found to be associated with the highest persistence rates and the lowest rates of medication switches. Non-adherence with anti-hypertensive treatment is currently a significant factor limiting any potential benefits achievable through cardiovascular risk factor control, and indeed, only about half of all patients have traditionally been believed to show persistence with treatment. The afore-mentioned “rule of halves” thus ex hypothesi casts doubts about the potential effectiveness of anti-hypertensive agents being unconditionally dependent solely on their capacity to lower blood pressure.

This was a nationwide, registry-based, new-user trial emulation study that leveraged multiple mandatory health-care registers in Sweden. The study period spanned from January 1, 2011, to December 31, 2019. Individuals who initiated antihypertensive therapy between 2011 and 2018 were eligible for inclusion. The analyses included patients starting treatment with one of the following antihypertensive drug classes: angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, calcium channel blockers, thiazide or thiazide-like diuretics, or single-pill combinations of two antihypertensive agents. A total of 341,182 patients met the inclusion criteria and were followed for up to five years.

Key findings:

• Compared to other drug classes, initiating antihypertensive therapy with an angiotensin receptor blocker was consistently associated with higher long-term persistence.ARB initiators were more likely to remain continuously on their original drug class and more likely to be on any antihypertensive therapy throughout follow-up.

• At three years, 44.7% (95% CI, 43.7–45.7) of patients who initiated therapy with an ARB were continuously persistent in their original drug class.

• When intermittent discontinuations were allowed, persistence to the original ARB class increased to 81.8% (95% CI, 80.9–82.8).

• In fact, when accounting for both intermittent discontinuations and switching between antihypertensive classes, roughly 80% of all new users of antihypertensive drugs, regardless of initial drug class, remained persistent to at least one antihypertensive medication over five years.

The initiation of therapy with an antihypertensive agent from the class of angiotensin receptor blockers showed the best sustained adherence with the fewest treatment changes over a period of five years. The present large-scale population-based study supports the reappraisal of hypotheses for adherence in the management of hypertension.

Reference:

Laurell, K., Gustafsson, S., Lampa, E., Zachariah, D., Ek, S., Rådholm, K., Martinell, M., & Sundström, J. (2025). Persistence to antihypertensive drug classes in uncomplicated hypertension: a nationwide Swedish cohort study. EClinicalMedicine, 103696, 103696. https://doi.org/10.1016/j.eclinm.2025.103696