Single-patient trials can find best medication for hypertensive kids

This is one of the first truly practical examples of personalised medicine I have seen: expert

There is no single blood pressure-lowering drug that works for most hypertensive children, but single-patient randomised crossover trials can be used to optimise their management, researchers report.

boy with hypertension

Dr Joyce Samuel and colleagues from McGovern Medical School at UT Health in Houston conducted individual trials in 32 children diagnosed with primary hypertension.

The approach can also be called an ‘n-of-1’ trial.

They prescribed three commonly used therapies (amlodipine, hydrochlorothiazide, and lisinopril) in randomised order for two-week treatment periods.

Next, they performed a second cycle of testing, this time trialling two medications for two-week periods.

A medication was excluded if it produced an unacceptable side effect, and the treatment that provided the biggest reduction in mean awake systolic BP was selected. 

Lisinopril was the preferred medication for 49% of children.

The preferred medication identified by the individual trials was generally not the same as prescribed before the study, with only 20% of patients continuing on the same medication, the researchers report in Paediatrics.

Six children had been taking multiple antihypertensive medications at enrolment, and five of these achieved adequate blood pressure control on monotherapy after their individual trial.

There were only modest overall differences between medications, but individual participants differed considerably in the measured effects on their blood pressure, with median differences between best-performing and worst-performing medications of 12mmHg.

"This individualised approach to antihypertensive medication selection holds potential value by involving patients in their own care and facilitating informed treatment decisions," the researchers conclude.

"In usual care, the choice of specific antihypertensive regimen is based on physician preference with little or no systematic assessment of treatment benefits and hazards."

Dr David Kaelber from Case Western Reserve University, Cleveland, US a paediatrician and expert in medical informatics, said: "Personalised medicine is one of those 'buzzwords' folks use a lot, but this is one of the first truly practical and effective example of personalized medicine that I have seen in paediatrics, outside of paediatric oncology.

"If your practice and patient/family with confirmed paediatric hypertension has the interest, time, and resources, the [individual trial] approach allows you to personalize medication treatment for paediatric hypertension," he said.

"The n-of-1 trials approach could potentially be applied to other paediatric and adult chronic conditions where multiple treatments may be appropriate for an individual patient and the physician and patient/family want to try a more personalised medicine approach."

More information: Pediatrics 2019.