[e-drug] Hydralazine deletion from 13th Model Essential Drug List

[Norman Olson <nolsonmd@aol.com>]

E-drug: Hydralazine deletion from 13th Model Essential Drug List
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Following an earlier posting on changes in the 13th WHO Model List
of Essential Medicines, hydralazine may have limited use as a
general antihypertensive, but I don't think it can be phased out at this
time. Vasodilator therapy with oral nitrates (isosorbide dinitrate tablets
remain on the list) and hydralazine were first shown to prolong life
and increase function in dilated cardiomyopathy in the early 1970s
and are still used occasionally in addition to angiotensin converting
enzyme inhibitors (ACEIs), beta blocker, spironolactone. They are
well-established effective therapy though a little inconvenient with
multiple doses of captopril until enalapril is more readily available.
Though ACEIs are now (barely) affordable, they are not tolerated in
almost 10% of people because of the bradykinin-induced cough they
produce. Angiotensin receptor blockers (ARBs) are the obvious and
effective substitute in developed countries, but these are clearly
unaffordable in poorer nations and still have many years to go on
their patents. Dilated cardiomyopathy is extremely common in
sub-Saharan Africa, affecting as many as 1/3 of inpatients in one
urban hospital I attend, but probably among the top 5 adult diagnoses
in many urban institutions, being both way under-reported as well as
under-treated. Hydralazine continues to find use in hypertension of
pregnancy and pre-eclampsia. We are a long way from settling
controversies over the best drug to use here (recent Cochrane
reviews), and hydralazine is still one of the affordable preferred ones
in pregnancy.
 
Also, It is still not clear that these more modern ACEIs or ARBs
provide the same benefits in black patients that they do in other
ethnic groups, and RCTs involving more Black patients are presently
in progress to answer this question. But any patient anywhere with
dilated cardiomyopathy having only a modest hypotensive response
to ACEIs associated with failure to improve is still reasonably treated
by the addition of hydralazine-nitrate therapy, perhaps also even an
ARB.
 
Norman D. Olson, MD
Global Health Ministries
Adj. Clin. Assoc. Prof. of Medicine
Stanford University
e-mail: nolsonmd@aol.com

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