A “beta” way to treat hypertension

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As we have learned more about the pathophysiology of hypertension, a host of new drug classes have been developed to target these various mechanisms. Many of these agents have much less in the way of side effects than earlier drugs; angiotensin converting enzyme (ACE) inhibitors and angiotensin 2 receptor antagonists, to cite two examples, are now widely used in children.

These drugs have displaced other categories of agents which, although effective, often had unacceptable side effects in children. Beta blockers such as propranolol, for example, have been less frequently employed because of troublesome features such as a sedating effect. Recently, however, new classes of beta blockers, with a more cardioselective profile and greater tolerability, have been used widely in adults. There has been a paucity of data upon which to base pediatric use of these agents.

In the current issue of The Journal, Batisky et al report an exceptionally well-designed trial of an extended release formulation of the beta 1 selective blocker metoprolol. The trial was powerful for a number of reasons, not the least of which was the presence of a placebo arm. Although some eyebrows might be raised by this, in reality, the risk to children with asymptomatic hypertension of the degree in this trial posed by a few weeks without treatment is close to nonexistent. On the other hand, the presence of this group makes the results of the trial even more meaningful. The drug proved safe and effective, with a very favorable side effect profile. An accompanying editorial by Chesney puts this trial into perspective. Currently, beta blockers are chosen as first-line agents by pediatric nephrologists less than 10% of the time; in contrast, the drugs are quite popular in adult medicine. The study of Batisky et al may set the stage for a major change in this approach.

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