The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) made numerous recommendations for first-line therapy for patients with high blood pressure. While JNC-7 places an emphasis on diuretics, it acknowledges the roles of several classes of hypertension drugs, including beta blockers, calcium channel blockers, ACE inhibitors, and two therapies that are fast gaining acceptance: AT-II receptor blockers and combination drugs.

The relationship between national guidelines for hypertensive therapy and formulary acceptance of those therapies is important. In no uncertain terms, JNC-7 makes the point that too many physicians ignore JNC guidelines and too few take aggressive steps to control their patients' blood pressure.

Angiotensin II receptor blockers (ARBs)

ARBs are a relatively new class of hypertension agents with a fast-growing body of literature behind them. JNC-7 identifies ARBs as acceptable second-line therapy or, in certain circumstances, first-line therapy alone or in combination with a diuretic. The medical establishment's acknowledgement of ARBs' potential may be helping ARBs gain relatively quick formulary acceptance by HMOs and PBMs.

Current formulary status of ARBs
  HMOs1 PBMs2
Approved/first or second tier 44% 37%
Approved/third tier 26% 32%
Covered/nonformulary/reimbursed 19% 18%
Prior authorization 8% 6%
Nonformulary/not reimbursed 3% 7%
1 MediMedia Information Technologies captures formulary data from 98 percent of HMOs. As of May 2003, ARBs were available on the first or second tier for 44 percent of commercial HMO members, and on the third tier for an additional 26 percent. Formularies covering 19 percent of HMO members do not list ARBs, meaning they are covered but the conditions of coverage are unspecified. Prior authorization is required in 8 percent of cases, while 3 percent of members are specifically denied a pharmacy benefit for this class.
2 As of May 2003, ARBs are listed on the first or second tier of 37 percent of PBM formularies. PBMs that reported formulary information are AdvancePCS, Caremark, Express Scripts, Medco Health Solutions, and National Prescription Administrators (NPA).

Combination therapy's resurgence

Largely shunned in medical and pharmacy teaching for decades, combination therapy — particularly for hypertension — has enjoyed a renaissance lately. JNC-7 states that that when a single agent is unable to control hypertension, practitioners should consider combination therapy. The JNC-7 report lists many fixed-dose combination agents that are suitable as second-line therapy or, in certain circumstances, for use in initiating therapy. Formulary acceptance trends for fixed-dose combination agents for hypertension would seem to signal increased P&T committee recognition of the role of combination therapy.

Combination therapy agents

Percent of all HMO members with access

This information is drawn from the MediMedia USA database Formulary Compass, which tracks medications on approximately 3,000 formularies in the U.S. representing HMOs, PPOs, Medicaid, PBMs and employer groups.


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