Methyldopa in the Treatment of Hypertension* - Profiles in Science
Methyldopa in the Treatment of Hypertension* - Profiles in Science
Methyldopa in the Treatment of Hypertension* - Profiles in Science
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<strong>Methyldopa</strong> <strong>in</strong> <strong>the</strong> <strong>Treatment</strong> <strong>of</strong> <strong>Hypertension*</strong><br />
BRUCE L. GILMORE, M.D.?<br />
Instructor <strong>in</strong> Yvfeciic<strong>in</strong>e, Georgetmn Unioersity School <strong>of</strong> Medic<strong>in</strong>e<br />
EDWARD 0.CREIS, M.D., F.A.C.P.<br />
S ISCE t,he <strong>in</strong>itial comm~~ni~ation <strong>of</strong> Oates et-<br />
all report<strong>in</strong>g that methyldopa lowered blood<br />
pressure <strong>in</strong> hypertensive patients additional stud-<br />
ies hal-e attested to <strong>the</strong> efficacy <strong>of</strong> this drug as<br />
an antihypertensi~e agent.‘-? Over <strong>the</strong> past 21/<br />
years methyldopa (Aldome@) has been utilized<br />
<strong>in</strong> this cl<strong>in</strong>ic usuaily <strong>in</strong> conjunction with sul-<br />
fonamide saluretic agents <strong>in</strong> <strong>the</strong> long-term treat-<br />
ment <strong>of</strong> hypertensive outpatients. The drug was<br />
compared with guanethid<strong>in</strong>e <strong>in</strong> 13 patients for<br />
pcriotls averag<strong>in</strong>g 6 months on each agent. In<br />
addition, adverse hcpnt,ic effects <strong>of</strong> met,hyldopa<br />
11:~~ been documented.<br />
Materials and Methods<br />
Dur<strong>in</strong>g <strong>the</strong> periotl <strong>of</strong> study 33 patients were<br />
treated <strong>in</strong> <strong>the</strong> hypertension cl<strong>in</strong>ic <strong>of</strong> <strong>the</strong> Mt.<br />
.JJto Veterans .~clrn<strong>in</strong>ist,ration Hospital with<br />
mcthylriopa. Tcvclvo patients had severe hyper-<br />
tension with 4 <strong>in</strong> <strong>the</strong> malignant phase, 19 with<br />
moilcr:lte hypcrtcnaion, and 2 with mild hyper-<br />
tcnsion.$ The me:m age was 45 years, and 25<br />
<strong>of</strong> <strong>the</strong> group were Scgroes. Only 3 !Jatients ex-<br />
nibitpd normal electrocardiograms, <strong>the</strong> majority<br />
&ow<strong>in</strong>g left ventricular hypertrophy. Twelve<br />
Il:ltic>nts had blootl urea nitrogrn levels prior to<br />
tllor:ll)y <strong>in</strong> excess <strong>of</strong> 25 mg. per 100 ml. <strong>of</strong> blood.<br />
The <strong>in</strong>terval bctxveen cl<strong>in</strong>ic visits averaged 2.5<br />
w-eek~. At each cl<strong>in</strong>ic visit, blood pressure record-<br />
<strong>in</strong>gs <strong>in</strong> <strong>the</strong> sup<strong>in</strong>e, sitt<strong>in</strong>g and crcct positions<br />
ww taken by a physici$ti. <strong>Methyldopa</strong> was ad-<br />
m<strong>in</strong>i~tcred <strong>in</strong> divided doses 3 times daily, Doses<br />
* Tilis stud:7 <strong>in</strong>s qqjorted <strong>in</strong> part by Grant H-720<br />
from I be United Stntrs Public Health Service.<br />
f Formerly Cl<strong>in</strong>irul Investigator, Veterans Adm<strong>in</strong>istration<br />
Hospital, Wash<strong>in</strong>gton, D.C.; present, address:<br />
1203 Sorth Quaker Lane, -Uexandria, Virg<strong>in</strong>ia 22302.<br />
1 In <strong>the</strong> hypertensive grad<strong>in</strong>g <strong>of</strong> patients we utilized<br />
<strong>the</strong> tnriter<strong>in</strong> <strong>of</strong> <strong>the</strong> Veterans .%dm<strong>in</strong>istration Cocperative<br />
Stud? on Antihypertensive -agents, published <strong>in</strong> “A<br />
doublr4l<strong>in</strong>d rontrol study <strong>of</strong> antihypertensive<br />
hh. Int. Med., 1960. 106, 81.<br />
agents,”<br />
Pr<strong>of</strong>essor <strong>of</strong> Medic<strong>in</strong>e, Georgetown University School <strong>of</strong> Medic<strong>in</strong>e; Senior Medi-<br />
cal Inwstigator, Veterans Adm<strong>in</strong>islration Hospital, Wash<strong>in</strong>gton<br />
13<br />
were adjusted at each cl<strong>in</strong>ic visit <strong>in</strong> order to ob-<br />
ta<strong>in</strong> optimal blood pressure control with<strong>in</strong> <strong>the</strong><br />
range <strong>of</strong> tolerable side-effects. The sulfonamide<br />
diuretics which were used were ei<strong>the</strong>r hydro-<br />
chlorothiazide, 50 mg. twice daily, or chlor-<br />
thalidone, 100 mg. once daily.<br />
Bromsulfale<strong>in</strong> (BSPf , serum alkal<strong>in</strong>e phospha-<br />
tase, serum glutamic oxaloacetic transam<strong>in</strong>ase<br />
(SGOT), and blood urea nitrogen (BUN) deter-<br />
m<strong>in</strong>ations were done after <strong>the</strong> patient had been<br />
<strong>in</strong>structed to fast overnight and omit breakfast.<br />
The amount <strong>of</strong> BSP retention was determ<strong>in</strong>ed<br />
accord<strong>in</strong>g to a modified method <strong>of</strong> Greene. Alka-<br />
l<strong>in</strong>e phosphatase was done by <strong>the</strong> method <strong>of</strong><br />
Bodansky. SGOT was determ<strong>in</strong>ed by a modified<br />
Reitman-Frankel method utiliz<strong>in</strong>g Dade@ re-<br />
agents, and <strong>the</strong> BUN was estimated with <strong>the</strong><br />
Technicon@ auto-analyzer.<br />
Remits<br />
Efiectiveness <strong>of</strong> <strong>the</strong>rapy. Blood pressure<br />
changes <strong>in</strong> only 24 patients will be discussed,<br />
s<strong>in</strong>ce <strong>in</strong>formation regard<strong>in</strong>g <strong>the</strong> percentage<br />
change <strong>in</strong> blood pressure was not pert<strong>in</strong>ent for 4<br />
patients whose methyldopa was discont<strong>in</strong>ued<br />
because <strong>of</strong> side-effects and for 5 patients who<br />
were transferred directly from guanethid<strong>in</strong>e to<br />
methyldopa without an <strong>in</strong>terven<strong>in</strong>g control pe-<br />
riod.<br />
Twelve <strong>of</strong> <strong>the</strong> 24 patients ei<strong>the</strong>r became nor-<br />
motensive or had average mean blood pressurel<br />
read<strong>in</strong>gs that were more than 20 per cent lower<br />
than <strong>the</strong> pretreatment mean pressures <strong>in</strong> both<br />
<strong>the</strong> sup<strong>in</strong>e and erect positions./ An additional 4<br />
patients exhibited average mean blood pressures<br />
dur<strong>in</strong>g <strong>the</strong> treatment period that were lower than<br />
<strong>the</strong>ir pretreatment levels by 20 per cent or more<br />
<strong>in</strong> <strong>the</strong> erect but not <strong>in</strong> <strong>the</strong> sup<strong>in</strong>e position. The<br />
3 Mean blood pressure = diastolic blood pressure +<br />
J/s pulse pressure.<br />
11 Detailed tabular data on <strong>in</strong>dividual cases can be .<br />
obta<strong>in</strong>ed by writ<strong>in</strong>g to <strong>the</strong> authors.
14 METHYLDOPA FOR HYI’ERTESSIOS-GILMORI: LSI) FRL;I~ Jauuarq, l!N%i<br />
average duration <strong>of</strong> <strong>the</strong>rapy <strong>in</strong> <strong>the</strong>se 16 patients<br />
was 40 weeks (range 13 to 96 weeks). The aver-<br />
age dose <strong>of</strong> methyldopa was 1,365 mg. (range<br />
540-2,375 mg.) per day. Fourteen <strong>of</strong> <strong>the</strong> 16 re-<br />
ceived saluretic agents concurrently.<br />
The rema<strong>in</strong><strong>in</strong>g 8 patients did not demonstrate<br />
reductions <strong>in</strong> <strong>the</strong>ir average blood pressures dur-<br />
<strong>in</strong>g <strong>the</strong> treatment period that were greater than<br />
10 per cent <strong>of</strong> <strong>the</strong>ir pretreatment values. The<br />
average maximum dose <strong>of</strong> methyldopa <strong>in</strong> <strong>the</strong>se<br />
patients was 1,906 mg. (range 1,750-3,000 mg.)<br />
per day. Seven <strong>of</strong> <strong>the</strong> 8 were treated concurrently<br />
with oral saluretic agents.<br />
Tolerance. The records <strong>of</strong> 10 patients who were<br />
ma<strong>in</strong>ta<strong>in</strong>ed with decreases <strong>of</strong> 20 per cent or more<br />
<strong>in</strong> mean blood pressure <strong>in</strong> <strong>the</strong> erect position<br />
were evaluated at 6 weeks, 3 months, and at <strong>the</strong><br />
end <strong>of</strong> <strong>the</strong>rapy. Dosage and blood pressure levels<br />
at <strong>in</strong>tervals as close as possible to <strong>the</strong>se periods<br />
were tabulated. Three <strong>of</strong> <strong>the</strong> 10 patients evi-<br />
denced manifestations <strong>of</strong> tolerance (table 1). The<br />
TABLE 1: Tolerance to Alpha Meth~ltlopa<br />
Blood Pressure<br />
(mm. Hg)<br />
Transient symptoms suggest<strong>in</strong>g ort,hostatic<br />
hypotension were noted <strong>in</strong> 20 <strong>of</strong> <strong>the</strong> 33 pnticnts.<br />
For <strong>the</strong> most part bhese symptoms consisted only<br />
<strong>of</strong> mild dizz<strong>in</strong>ess on aris<strong>in</strong>g <strong>in</strong> <strong>the</strong> morn<strong>in</strong>g, but<br />
3 patients experienced syncope which did not rc-<br />
cur when dosage was rcduccd.<br />
Four patients compla<strong>in</strong>ed <strong>of</strong> dim<strong>in</strong>ished sesual<br />
drive after beg<strong>in</strong>n<strong>in</strong>g methyldopa. In 1 caac re-<br />
duction <strong>in</strong> dosage sufficed to restore potency. In<br />
ano<strong>the</strong>r patient <strong>the</strong> addition <strong>of</strong> n placebo with-<br />
out reduction <strong>in</strong> t’he dose <strong>of</strong> methyldopa led to<br />
restoration <strong>of</strong> normal potency. In <strong>the</strong> 2 rema<strong>in</strong>-<br />
<strong>in</strong>g patients <strong>the</strong> compla<strong>in</strong>t cont<strong>in</strong>ued after <strong>the</strong>ir<br />
treatment was changed. It is, <strong>the</strong>refore, unlikely<br />
that <strong>the</strong> impotence was related to mcthyldopa <strong>in</strong><br />
3 <strong>of</strong> <strong>the</strong> 4 patients.<br />
Four patients voluntecrcd that <strong>the</strong>y were har-<br />
<strong>in</strong>g frequent dreams which seemed to be related<br />
to <strong>the</strong>rapy. The dreams ceased, howcvcr, despite<br />
cont<strong>in</strong>uation <strong>of</strong> treatment. Four patients com-<br />
pla<strong>in</strong>ed <strong>of</strong> “tenseness” and nerl*ousness while<br />
Duration <strong>of</strong> <strong>Treatment</strong><br />
6 weeks 3 months F<strong>in</strong>al’<br />
Daily Dose IDa$D;SC<br />
Daily Dose<br />
Alpha Blood Pressure<br />
Blood Pressure .4lpha<br />
<strong>Methyldopa</strong><br />
pm. Hg) <strong>Methyldopa</strong> ,mm. Hg)<br />
bw.)<br />
us-.) Me:h~l~;pa 6<br />
Sup<strong>in</strong>e Stand<strong>in</strong>g Sup<strong>in</strong>e Stand<strong>in</strong>g Sup<strong>in</strong>e I Stand<strong>in</strong>g<br />
Tolerant patients (3)<br />
I---------------<br />
157/103 159/112 1,333 173/113 163/116 1,500 165/114 ~ 170/114 2,150<br />
Nontolerant patients (7) 145/96 131/95 1,000 147/99 140/105 1,214 133’g6 ’ 118/88<br />
I<br />
1,321<br />
* Average duration <strong>of</strong> treatment for tolerant patients, 6 months; for nontolerant patients, 12 months.<br />
average daily dose <strong>of</strong> <strong>the</strong>se patients at 6 weeks<br />
was 1,333 mg. and at 6 months 2,450 mg., all <strong>of</strong><br />
<strong>the</strong> patients be<strong>in</strong>g treated throughout with<br />
saluretic agents. The blood pressure was slightly<br />
higher at 6 months despite <strong>the</strong> higher doses. In<br />
<strong>the</strong> rema<strong>in</strong><strong>in</strong>g 7 patients <strong>the</strong> average daily dose<br />
was 1,000 mg. at 6 weeks and 1,321 mg. at 12<br />
months with <strong>the</strong> average blood pressure lower at<br />
<strong>the</strong> 12-month <strong>in</strong>terval. Five <strong>of</strong> <strong>the</strong>se 7 patients<br />
were treated concurrently with saluretic agents<br />
throughout <strong>the</strong> entire period.<br />
Side-effects. Side-effects were m<strong>in</strong>imal. Drow-<br />
s<strong>in</strong>ess at <strong>the</strong> <strong>in</strong>it,iation <strong>of</strong> treatment was noted <strong>in</strong><br />
most patients. It usually disappeared after sev-<br />
eral days on a given dose to recur aga<strong>in</strong> for a<br />
few days if <strong>the</strong> dose was <strong>in</strong>creased. One patient,<br />
however, experienced persistent drows<strong>in</strong>ess over<br />
<strong>the</strong> course <strong>of</strong> 6 months, with <strong>the</strong> result that his<br />
employer compla<strong>in</strong>ed that <strong>the</strong> patient was con-<br />
stantly fall<strong>in</strong>g asleep at his desk.<br />
tak<strong>in</strong>g methyldopa. O<strong>the</strong>r compla<strong>in</strong>ts less fre-<br />
quently encountered were dry mouth <strong>in</strong> 2 cases,<br />
headaches. <strong>in</strong> 2, and constipation <strong>in</strong> 1. These<br />
m<strong>in</strong>or subjective compla<strong>in</strong>ts were not neces-<br />
sarily related to <strong>the</strong> use <strong>of</strong> <strong>the</strong> drug.<br />
Side-effects necessitat<strong>in</strong>g discont<strong>in</strong>uation <strong>of</strong><br />
methyldopa occurred <strong>in</strong> only 3 <strong>in</strong>stances. In 1,<br />
referred to above, persistent drows<strong>in</strong>ess ceased<br />
when <strong>the</strong> patient’s <strong>the</strong>rapy was changed to<br />
guanethid<strong>in</strong>e. A second patient compla<strong>in</strong>ed <strong>of</strong><br />
vomit<strong>in</strong>g and headaches which came on ap-<br />
proximately 20 m<strong>in</strong>utes after tak<strong>in</strong>g his medi-<br />
cations. These symptoms recurred on 2 separate<br />
trials, and <strong>the</strong> patient refused fur<strong>the</strong>r treatment<br />
with <strong>the</strong> drug. One o<strong>the</strong>r patient developed a<br />
macular, pruritic sk<strong>in</strong> eruption after 4 weeks <strong>of</strong><br />
methyldopa <strong>the</strong>rapy. The rash cleared com-<br />
pletely with<strong>in</strong> 2 weeks <strong>of</strong> discont<strong>in</strong>u<strong>in</strong>g treat-<br />
ment, and a second trial <strong>of</strong> <strong>the</strong> drug was not<br />
attempted.<br />
-
I)r!ig reactions. Fever and alterations <strong>in</strong><br />
Il
~ETHYLD~P~ FOR HYPERTENsIO~-GIL~~ORE hm FREIS January, 1965<br />
had manifested erratic control while tak<strong>in</strong>g<br />
guanethid<strong>in</strong>e with hydro~hlorothiazide for 27<br />
weeks was transferred to methyldopa and chlor-<br />
thalidone. He ma<strong>in</strong>ta<strong>in</strong>ed lower blood pressure<br />
levels dur<strong>in</strong>g 18 weeks <strong>of</strong> treatment with <strong>the</strong><br />
latter drug <strong>in</strong> an average daily dose <strong>of</strong> 2,000 mg.<br />
Higher blood pressures <strong>the</strong>n recurred <strong>in</strong> spite <strong>of</strong><br />
<strong>in</strong>creas<strong>in</strong>g doses. The blood urea nitrogen level<br />
had been 61 mg. per 100 ml. at <strong>the</strong> beg<strong>in</strong>n<strong>in</strong>g <strong>of</strong><br />
methyldopa <strong>the</strong>rapy. Because <strong>of</strong> his mental con-<br />
fusion it is not certa<strong>in</strong> that he took his pills cor-<br />
rectly dur<strong>in</strong>g this period. He subsequently died<br />
<strong>in</strong> renal failure. The 2 rema<strong>in</strong><strong>in</strong>g patients <strong>in</strong> <strong>the</strong><br />
series, both with moderate hypertension, ma<strong>in</strong>-<br />
ta<strong>in</strong>ed equally good control with ei<strong>the</strong>r methyl-<br />
dopa or guanethid<strong>in</strong>e.<br />
Symptoms <strong>of</strong> orthostatic hypotension lvere<br />
more frequent and <strong>of</strong> greater severity while <strong>the</strong><br />
patients were tak<strong>in</strong>g guanethid<strong>in</strong>e. However, <strong>in</strong><br />
no case was it necessary to discont<strong>in</strong>ue treatment<br />
with guanethid<strong>in</strong>e because <strong>of</strong> orthostatic hypo-<br />
tension; brief discont<strong>in</strong>uance and subsequent re-<br />
duction <strong>of</strong> dosage were sufficient to alleviate <strong>the</strong><br />
problem.<br />
Seven <strong>of</strong> <strong>the</strong> 13 patients developed failure <strong>of</strong><br />
ejaculation while tak<strong>in</strong>g guanethid<strong>in</strong>e. In no<br />
ease, however, was guanethid<strong>in</strong>e discont<strong>in</strong>ued<br />
because <strong>of</strong> this side-effect although <strong>the</strong> patients<br />
were <strong>in</strong>formed that guanethid<strong>in</strong>e was <strong>the</strong> causa-<br />
tive agent. Only 1 <strong>of</strong> <strong>the</strong> 13 patients compla<strong>in</strong>ed<br />
<strong>of</strong> any change <strong>in</strong> sexual function while tak<strong>in</strong>g<br />
methyldopa. This consisted <strong>of</strong> transitory impo-<br />
tence respond<strong>in</strong>g to a brief reduction <strong>in</strong> dosage.<br />
In spite <strong>of</strong> <strong>the</strong> side-effects noted above, none <strong>of</strong><br />
<strong>the</strong> 13 patients expressed a preference for meth-<br />
yldopa over ~anethid<strong>in</strong>e. Two patients had<br />
occasional episodes <strong>of</strong> diarrhea while tak<strong>in</strong>g<br />
guanethid<strong>in</strong>e whereas none compla<strong>in</strong>ed <strong>of</strong> bowel<br />
disturbances with methyIdopa.<br />
Blood urea nitrogen levels were taken serially<br />
<strong>in</strong> 10 patients prior to and after completion <strong>of</strong> at<br />
least several months on each type <strong>of</strong> <strong>the</strong>rapy.<br />
Exclud<strong>in</strong>g <strong>the</strong> patient who died <strong>in</strong> renal failure<br />
<strong>the</strong> average blood urea nitrogen level was 32 mg.<br />
per cent dur<strong>in</strong>g methyldopa treatment as com-<br />
pared to 36 mg. per cent dur<strong>in</strong>g treatments with<br />
guanethid<strong>in</strong>e. The difference was not statistically<br />
significant and could be accounted for entirely by<br />
<strong>in</strong>crease <strong>in</strong> blood urea nitrogen <strong>in</strong> 2 asotemic<br />
patients whose diastolic blood pressure levels <strong>in</strong><br />
<strong>the</strong> erect position were 18 and 25 mm. Hg lower,<br />
respectively, dur<strong>in</strong>g <strong>the</strong> guanethid<strong>in</strong>e treatment<br />
period. In 1 <strong>of</strong> <strong>the</strong>se patients a reduction <strong>in</strong><br />
guanethid<strong>in</strong>e dosage with consequent higher<br />
orthostatic blood pressures resulted <strong>in</strong> lower<br />
levels <strong>of</strong> blood urea nitrogen.<br />
Comments<br />
In <strong>the</strong> present study methyldopa <strong>in</strong> conjunc-<br />
tion with oral diuretics proved effective <strong>in</strong> ma<strong>in</strong>-<br />
ta<strong>in</strong><strong>in</strong>g significant decreases <strong>in</strong> blood pressure <strong>in</strong><br />
16 <strong>of</strong> 24 patients. The use <strong>of</strong> saluretic agents<br />
seems <strong>in</strong>dicated <strong>in</strong> view <strong>of</strong> <strong>the</strong> potentiation <strong>of</strong><br />
action <strong>of</strong> methyldopa noted by ourselves as well<br />
as o<strong>the</strong>rs.2~ 3, 0, i, lo, I* Fur<strong>the</strong>rmore, problems <strong>of</strong><br />
fluid retention noted occasionally on adm<strong>in</strong>istra-<br />
tion <strong>of</strong> methyldopa”~ 7, l2 were obviated. Dollery<br />
and Har<strong>in</strong>gton’ used methyldopa alone <strong>in</strong> doses<br />
up to 4.0 Gm. daily. Seven <strong>of</strong> 59 patients failed<br />
to respond. Cannon et al* employed doses up to<br />
8.0 Gm. per day and reported that 31 <strong>of</strong> 33 pa-<br />
tients had a significant response, Onesti et allo<br />
adm<strong>in</strong>istered up to 2.8 Gm. per day and found<br />
that 13 <strong>of</strong> 24 patients obta<strong>in</strong>ed a significant anti-<br />
hypertensive response <strong>in</strong> <strong>the</strong> erect, position; when<br />
hydrochlorothiazide was added <strong>in</strong> 7 nonre-<br />
sponders, 6 <strong>of</strong> <strong>the</strong>se obta<strong>in</strong>ed a significant fall <strong>in</strong><br />
blood pressure.<br />
Tolerance to methyldopa has been noted by<br />
o<strong>the</strong>r <strong>in</strong>vestigators. Cannon et, al-” noted that <strong>the</strong><br />
dosage requirement <strong>of</strong> most patients <strong>in</strong>creased<br />
somewhat after <strong>the</strong>y were discharged from <strong>the</strong><br />
hospital. Two <strong>of</strong> <strong>the</strong>ir 33 patients required dis-<br />
cont<strong>in</strong>uation <strong>of</strong> methyldopa because <strong>of</strong> tolerance<br />
after 7 and 11 months, respectively. Dollery and<br />
War<strong>in</strong>gton’ noted that some <strong>in</strong>crease <strong>in</strong> dosage<br />
was <strong>of</strong>ten necessary on <strong>the</strong> early outpatient<br />
visits after patients ‘;i’ere discharged from <strong>the</strong><br />
hospital. They also observed that a small num-<br />
ber <strong>of</strong> <strong>the</strong>ir patients cont<strong>in</strong>ued to require <strong>in</strong>-<br />
creas<strong>in</strong>g dosages dur<strong>in</strong>g prolonged t#reatment.<br />
Bayliss and Harvey-Snnth”2 noted tolerance <strong>in</strong><br />
4 <strong>of</strong> <strong>the</strong>ir 20 cases so that doses <strong>of</strong> 3 Gm. or more<br />
per day were no longer effective. Daley and<br />
Evansi noted significant tolerance <strong>in</strong> 2 <strong>of</strong> 20<br />
patients. SrnirkO reported that <strong>in</strong>creased doses<br />
were required to ma<strong>in</strong>ta<strong>in</strong> <strong>the</strong> <strong>in</strong>itial blood pres-<br />
sure falls <strong>in</strong> 6 <strong>of</strong> 14 patients. In 2 <strong>of</strong> <strong>the</strong>se pa-<br />
tients <strong>the</strong> <strong>in</strong>creases were nearly 3-fold. In <strong>the</strong><br />
present study it was found that while 3 <strong>of</strong> 10<br />
patients manifested tolerance, requir<strong>in</strong>g an aver-<br />
age dose at 6 months that was nearly double<br />
<strong>the</strong> average dose at G weeks, <strong>the</strong> rema<strong>in</strong><strong>in</strong>g 7 pa-<br />
tients did not manifest tolerance after an aver-<br />
age <strong>of</strong> 12 months <strong>of</strong> cont<strong>in</strong>uous treatment.<br />
Drug reactions to n~ethyldopa were first noted<br />
by Gillespie and co-workers.” They rel)orted 2<br />
patients who developed fever with<strong>in</strong> 2 weeks<br />
after <strong>the</strong> <strong>in</strong>itiation <strong>of</strong> treatment \vith racemic<br />
mcthyldopa. Discont<strong>in</strong>uance <strong>of</strong> medication was<br />
associated with cessation <strong>of</strong> fever <strong>in</strong> both pa-<br />
tients. On readm<strong>in</strong>istration <strong>of</strong> <strong>the</strong> thug, fcvcr
l~,ll. &, . \’ 0. I .\IEDIC;\L .$SS;iLS OF THE DISTRICT OF COLUNBIA 17<br />
I~c7,~i~rrccl <strong>in</strong> 1 patient Gth<strong>in</strong> 3 days. In <strong>the</strong> second<br />
1b;iticnt fci-cr did not recur with rcatlm<strong>in</strong>istr~tion,<br />
I,iit c~lcv:~tions <strong>of</strong> serum alkal<strong>in</strong>e phosphutnse,<br />
ri~;m.~:~<strong>in</strong><strong>in</strong>:~sc antI bilirub<strong>in</strong> levels similar to<br />
rliose that had been Inesent with fever recurred<br />
jvith<strong>in</strong> 2 days. Leonard et al8 reported 3 patients<br />
<strong>in</strong> whom febrile reactions occurred with<strong>in</strong> 3<br />
\v(~ks <strong>of</strong> <strong>in</strong>itiation <strong>of</strong> treatment. <strong>Methyldopa</strong><br />
1~;~s reachu<strong>in</strong>istered to 2 <strong>of</strong> <strong>the</strong>se patients with<br />
re1iroduction <strong>of</strong> <strong>the</strong> fever. Sheps et al9 reported<br />
that fever occurred with<strong>in</strong> 3 weeks <strong>of</strong> <strong>in</strong>itiation<br />
<strong>of</strong> methyltlopa <strong>in</strong> one <strong>of</strong> his patients and was<br />
:is:aoriatccl Iv-it11 an elevated serum glutamic<br />
osaloacctic transam<strong>in</strong>ase level. The latter be-<br />
C;UW normal 10 days after discont<strong>in</strong>uation <strong>of</strong><br />
<strong>the</strong> drug. Retest<strong>in</strong>g was not accomplished <strong>in</strong><br />
this case. One brief note <strong>of</strong> <strong>the</strong> results <strong>of</strong> liver<br />
t)iol)sy <strong>in</strong> ano<strong>the</strong>r patient has been recorded.”<br />
Thr liver bec:mie normal with discont<strong>in</strong>uation <strong>of</strong><br />
methyldopa <strong>in</strong> this patient, but it is not stated<br />
whe<strong>the</strong>r retest<strong>in</strong>g was undertaken.<br />
Tlir patient with hepatic <strong>in</strong>jury <strong>in</strong> <strong>the</strong> present<br />
&c’s represents <strong>the</strong> first reported case demonstrat<strong>in</strong>g<br />
hcpatic changes by biopsy dur<strong>in</strong>g t.he<br />
:icute illness and recurrence <strong>of</strong> alterations <strong>of</strong><br />
hcalj;rtic function tests when metliyldopa was<br />
f~catl~~l<strong>in</strong>istcl~ctl. &reral po<strong>in</strong>ts arc, <strong>the</strong>refore, <strong>of</strong><br />
<strong>in</strong>ttrcst. The alterations present <strong>in</strong> <strong>the</strong> biopsy<br />
~liec<strong>in</strong>ien ncrc consistent with 3 hypersensitivity<br />
rcx:iction with spotty necrosis but were not typical<br />
<strong>of</strong> “allergic cliolangiolitie” with bile stasis’”<br />
w .>cen n-ith chlorpromaz<strong>in</strong>e. The tests that were<br />
uio~t u~ful <strong>in</strong> follolv<strong>in</strong>g <strong>the</strong> hepatic <strong>in</strong>jury were<br />
thca ~(7uni glutamic oxaloacetic transam<strong>in</strong>ase,<br />
tlicx cc~1~li:il<strong>in</strong> florculntion test, and bromsulfale<strong>in</strong><br />
retention. Elel-ation <strong>of</strong> <strong>the</strong> serum glutamic<br />
osalo:icctic transtlm<strong>in</strong>ase lcvcl and a change <strong>in</strong><br />
rc1ihal<strong>in</strong> flocculation tlid not occur until 9 days<br />
after <strong>the</strong> start <strong>of</strong> retest<strong>in</strong>g and p,ersisted for at<br />
Icast. 2 weeks after nietl~pldol~a ~-as discont<strong>in</strong>ued.<br />
Rrl-iew <strong>of</strong> <strong>the</strong> literature <strong>in</strong>dicates that fever<br />
and alteration <strong>of</strong> hcpatic function tests are <strong>in</strong>frequent<br />
complications <strong>of</strong> <strong>the</strong> use <strong>of</strong> methyldopa.<br />
So case <strong>of</strong> death or permanent alteration<br />
<strong>of</strong> he1ratic function has been reported. It appears<br />
that he1)atic <strong>in</strong>jury <strong>in</strong>duced by methyldopa requircls<br />
some type <strong>of</strong> <strong>in</strong>dividual hypersensitivity<br />
to <strong>the</strong> tlrug and is reversible<br />
tion <strong>of</strong> <strong>the</strong> drug.<br />
with discont<strong>in</strong>ua-<br />
Jloat <strong>in</strong>vestigators have noted that methyldopa<br />
produces less orthostatic hypotension than<br />
(1~~ gu:mcthicl<strong>in</strong>e. The results <strong>in</strong> <strong>the</strong> 13 cases<br />
reported above <strong>in</strong> which guanethid<strong>in</strong>c and methvltlo1ia<br />
wcrc compared is consistent with this<br />
i<strong>in</strong>prcs~ion. In review<strong>in</strong>g <strong>the</strong> literature, average<br />
sup<strong>in</strong>e anal erect blood pressures <strong>of</strong> 62 patients<br />
treated with methyldopa alone, reported <strong>in</strong> 5<br />
articles,“, 1~ 11, l6. 17 were 159/95 mm. Hg and<br />
141/91 mm. Hg, respectively. Average sup<strong>in</strong>e and<br />
erect blood pressures <strong>of</strong> 62 patients who were<br />
treated with guanethid<strong>in</strong>e alone, reported <strong>in</strong> 5<br />
different articles,ys-22 were 169/103 mm. Hg and<br />
134/90 mm. Hg, respectively. Tests for stat’istical<br />
significance were not attempted for obvious rea-<br />
sons, but <strong>the</strong> f<strong>in</strong>d<strong>in</strong>g <strong>of</strong> lower sup<strong>in</strong>e pressures<br />
with methyldopa when orthostatic diastolic<br />
pressures were equivalent tends to substantiate<br />
a widely held cl<strong>in</strong>ical impression.<br />
In spite <strong>of</strong> <strong>the</strong> higher <strong>in</strong>cidence <strong>of</strong> side-effects<br />
while tak<strong>in</strong>g guanethid<strong>in</strong>e, patients cont<strong>in</strong>ued to<br />
take <strong>the</strong>ir medications and none requested a re-<br />
sumption <strong>of</strong> methyldopa. Many patients pre-<br />
ferred <strong>the</strong> small number <strong>of</strong> tablets and once<br />
daily adm<strong>in</strong>istration associated with guanethi-<br />
d<strong>in</strong>e. The shorter onset and effective duration <strong>of</strong><br />
action <strong>of</strong> methyldopa were occasionally found to<br />
constitute a practical advantage. Initiation <strong>of</strong><br />
effective <strong>the</strong>rapy can be more rapid, and ortho-<br />
static hypotension, if it occurs, can be elim<strong>in</strong>ated<br />
more rapidly through a reduction <strong>in</strong> dosage.<br />
<strong>Methyldopa</strong> was not compared with drug<br />
regimens generally used for less severe hyper-<br />
tension <strong>in</strong> this cl<strong>in</strong>ic, namely, reserp<strong>in</strong>e plus<br />
saluretic agents or reserp<strong>in</strong>e, saluretic agents<br />
and small doses <strong>of</strong> hydralaz<strong>in</strong>e. The low <strong>in</strong>ci-<br />
dence <strong>of</strong> side-effects, lack <strong>of</strong> orthostatic hypo-<br />
tension, simpler titration <strong>of</strong> dosages, and equiva-<br />
lent frequency <strong>of</strong> adm<strong>in</strong>istration (3 or 4 times<br />
daily with hydralaz<strong>in</strong>e) would seem to contra-<br />
dict replacement <strong>of</strong> <strong>the</strong>se regimens with methyl-<br />
dopa as <strong>the</strong> first choice <strong>of</strong> treatment <strong>in</strong> most<br />
patients with benign hypertension.<br />
Summary<br />
Twenty-four male patients with moderate to<br />
severe hypertension were treated with methyl-<br />
dopa for an average period <strong>of</strong> 9 months (range<br />
2.5 to 22 months). The mean daily dose was<br />
1,390 mg., usually <strong>in</strong> conjunction with a ealu-<br />
retie agent. Sixteen <strong>of</strong> <strong>the</strong> 24 patients ma<strong>in</strong>-<br />
ta<strong>in</strong>ed a significant reduction <strong>of</strong> blood pressure.<br />
Tolerance was observed <strong>in</strong> 3 cases. The side-<br />
effects were m<strong>in</strong>imal and consisted pr<strong>in</strong>cipally <strong>of</strong><br />
drows<strong>in</strong>ess dur<strong>in</strong>g <strong>the</strong> <strong>in</strong>itial period <strong>of</strong> treatment.<br />
Two <strong>in</strong>stances <strong>of</strong> febrile reactions associated<br />
with disturbances <strong>in</strong> liver function tests were<br />
observed. Abnormalities <strong>of</strong> liver function re-<br />
curred when methyldopa was re<strong>in</strong>stituted. In 1<br />
<strong>of</strong> <strong>the</strong>se patients needle biopsy taken dur<strong>in</strong>g <strong>the</strong><br />
acute illness demonstrated toxic <strong>in</strong>jury to liver<br />
cells compatible with drug-<strong>in</strong>duced hepatitis.
18 METHYLDOPA FOR HYPERTENSIOK-GILRIORE ASD FREIS January, 1965<br />
7vIethyldopa was compared with guanethid<strong>in</strong>e<br />
<strong>in</strong> 13 patients. <strong>Treatment</strong> with methyldopa was<br />
associated with fewer side-effects than with<br />
guanethid<strong>in</strong>e but was not preferred by most pa-<br />
tients, largely because <strong>of</strong> <strong>the</strong> large number <strong>of</strong><br />
tablets and greater frequency <strong>of</strong> dosage required.<br />
Orthostatic reduction <strong>of</strong> blood pressure usually<br />
was greater with guanethid<strong>in</strong>e.<br />
<strong>Methyldopa</strong>, <strong>in</strong> <strong>the</strong> form <strong>of</strong> Aldome@, was supplied<br />
by Dr. E. L. Foltz <strong>of</strong> Merck, Sharp and Dohme. We<br />
wish to thank Drs. Jay N. Cohn, William C. Heath,<br />
Myron H. Luria, Flavio D. Sassen and Harold D.<br />
Schnaper who participated <strong>in</strong> <strong>the</strong> cl<strong>in</strong>ic management <strong>of</strong><br />
<strong>the</strong> above reported patients.<br />
1:<br />
2.<br />
3.<br />
4.<br />
5.<br />
6.<br />
7.<br />
8.<br />
9.<br />
10.<br />
11.<br />
12.<br />
13.<br />
14.<br />
15.<br />
16.<br />
17.<br />
18.<br />
19.<br />
20.<br />
21.<br />
22.<br />
References<br />
0.4~~s. J. 9., GILLESPIE, L., JR., UDENFRIEND, S., AND 13.<br />
SJOERDSsf.4, A.: <strong>Science</strong>, 1960, 131, 1890. 14.<br />
DOLLERI., C. T., AND HARINGTON, M.: Lancet, 1962, 1,<br />
759. 15.<br />
GILLESPIE, L., JR., OATES, J. A., CROUT, J. R., AND<br />
SJ~ERDSX~, A.: Circulation, 1962, 25, 281.<br />
CASNON, P. J., .4ND OTHERS: J.A.M.A., 1962, 179, 673.<br />
IRVINE, R. 0. H., O’BRIEN, K. P., AND NORTH, J. G.<br />
K. : Lancet, 1962, 1, 300.<br />
&IRK, H.: Brit. Med. J., 1963, 1, 146.<br />
HAMILTOX, M., AND KOPELMAN, H.: Ibid., 1963, 1, 151.<br />
LEONARD, J. W., GIFFORD, R. W., AND HUIPHREY,<br />
D. C.: Cleveland Cl<strong>in</strong>. Quart., 1962, 29, 144.<br />
SHEPS, S. G., SCHIRGER, P. J., AND FAIRBAIRS, J. F.:<br />
J.A.M.rl., 1963, 184,616.<br />
OXESTI, G., BREST, A. N., NOVACK, P., AND MOYER,<br />
J. H.: Amer. J. Cardiol., 1962, 9, 863.<br />
KIRKENDALL. W. M., AND WILSON, W. R.: Ibid., 1962,<br />
9, 107.<br />
BAYLISS, R. I. S., AND HARVEY-SMITH, E. A.: Lancet,<br />
1962,1,763.<br />
D.~Lc(, D., ASD EVANS, B.: Brit. Med. J., 1962, 2, 156.<br />
Seventh International Congress <strong>of</strong> Internal Medi-<br />
c<strong>in</strong>e: Panel discussion on alpha-methyldopa. Appl.<br />
Ther., 1962,4, 1137.<br />
POPPER, H., ASD SCHAFFNER, F.: Liver: Structure and<br />
Function. New York: McGraw-Hill, 1957, p. 403.<br />
WEIL, M. H., BARBOUR, B. H., AKD CHESNE, R. B.:<br />
Circulation, lQ63,28, 165.<br />
BREST, A. N., AXD MOYER, J. H.: Amer. J. Cardiol.,<br />
1962,9, 116.<br />
MARONDE, R. F., HAYWARD, L. J., AKD BARBOUR, B.:<br />
Amer. J. Med. Sci., 1961, 242, 132.<br />
RIRKENDALL, W. M., AND OTHERS: Hemodynamir and<br />
cl<strong>in</strong>ical effects <strong>of</strong> guanethid<strong>in</strong>e, presented at thf<br />
*Symposium on Guanethid<strong>in</strong>e, held at <strong>the</strong> Univer-<br />
sity <strong>of</strong> Tennessee College <strong>of</strong> Medic<strong>in</strong>e <strong>in</strong> Mcm-<br />
phis, April 22,196O.<br />
FROHLICH, E. D., .~ND FREIS, E. D.: Cl<strong>in</strong>ical evalua-<br />
tion <strong>of</strong> guanethid<strong>in</strong>e-a postganglionir sympa-<br />
<strong>the</strong>tic block<strong>in</strong>g agent. Ibid.<br />
CHAXDRASEKAR, R. G., AND OTHERS: Amer. Heart J.,<br />
1962,63,309.<br />
P.AGE, I. H., AXD Dus~ax, H. P.: J.A.M.A.. 1959, 170,<br />
1265.<br />
3.<br />
4.<br />
5.<br />
6.<br />
7.<br />
Licorice for Salt-los<strong>in</strong>g Nephritis-Parrish<br />
(Con timed from page 3)<br />
PETERS, J. P., WAICEUAN, A. M., EISES~IAX, .4. J., .~ND<br />
LEE, C.: J. Cl<strong>in</strong>. Invest., 1929, 6, 517.<br />
LEVERE, A. H., AND WESSON, L. G., JR.: Sew Eng. J.<br />
Med., 1956, 255,373.<br />
N~SSBAUM, H. E., BERXHARD, W’. G., ASD M.~TTIA,<br />
V. D., JR.: Ibid., 1952, 246, 289.<br />
JOINER, C. L., AND THORNE, M. G.: Lnncet, 1052, 2,<br />
454.<br />
MURPHY, R. TT., COFFYAK, E. W., PRISGLE, B. H., AND<br />
ISERI, L. T.: Arch. Intern. Med. (Chicago), 1952,<br />
90,750.<br />
FALSETTI, H., AND KUSIX, A. S.: New Eng. J. Med.,<br />
8.<br />
1963, 268,598.<br />
9. SAWYER, W. H., AXD SOLEZ, C.: Ibid., 1949, 240, 210.<br />
10. MURPHY, F. D., SETTIXI, A. L., ASD IiozoEioFF, N. J.:<br />
Ann. Intern. Med., 1953,38,1160.<br />
11. BORST, J. R.: Arta Mrd. &and., 194Q, 136, 1.<br />
12. REVERS, F. E.: Nederl. T. Geneesk., 1946, 90, 135.<br />
MOLHUYSEX, J. A.,. .4sD OTHERS: LancetY 1950, 2, 381.<br />
GHOEX, J., PELSER, H., WILLEBR~NDS? 11. F., AE~D KAY-<br />
JIISGA, C. E.: Sew Eng. J. Med., 1951, 244, 471.<br />
R~ZICKA, L., AXD LEUESBERCER, H.: Hclv. Cl<strong>in</strong>. .\cta,<br />
1936, 19, 1402.<br />
.^<br />
~ti, CARD? W. I., ASD OTHERS: Lancet? 1953, 1, 663.<br />
Ii. GALAL, E. E.: Brit. J. Pharmacol.. 1955, 10, 305.<br />
18. HUDSOX, P. B., MITTLEXAN, A.. AXD PODBERECEC, M.:<br />
New Eng. J. Med., 1954,251,641.<br />
19. LOUIS, L. H., ASD COSN, J. W.:<br />
1956, 47,20.<br />
J. Lab. Cl<strong>in</strong>. Med.,<br />
20. CAPRETTI, G., .4SD M4GSAN1, B.: Gior. Cl<strong>in</strong>. Med.,<br />
1953,34,649.<br />
21. KRAUS, S. D.: J. Esp. Med., 1957, 106, 416.<br />
22. KRAUS, S. D.: Ibid.: 1958, 108, 325.<br />
23. VASDER, A. J.. AXD OTHERS: Proc. Sot. Esp. Biol.<br />
Med., 1958,99,323.<br />
24. WESSOS, L. G.> JR., .~SD AXSLO~, W. P., JR.: Amer.<br />
J. Physiol., 1948, 153,465.<br />
25. ULLRICH, K. J., ASD OTHERS: Ibid., 1963, 204, 527.<br />
26. MALVIX, R. L., WILDE, W. S.> VANDER, A. J., AND<br />
SCLLIVAIZ., L. P.: Ibid.. 1958, 195, 549.<br />
Advances <strong>in</strong> Cl<strong>in</strong>ical Electrodiagnosis-Zohn<br />
(Conti,lwr/ jrom page 12)<br />
References<br />
1. RODRIQLTEZ, A. A., ASD OESTER, Y. T., <strong>in</strong> Licht, S.,<br />
editor: Electrod<strong>in</strong>gnosis and Electromyography,<br />
2nd ed. New Haven, Conn.: Elizabeth Licht, 1961,<br />
chap. 12.<br />
2. ROGOFF, J. B.: Cl<strong>in</strong>ical electromyography: usefulness<br />
<strong>in</strong> differentiat<strong>in</strong>g myopathies from neuropathies.<br />
New York J. Med., 1960,60,512.<br />
3. CLIPPINGER, F. W., GOLDYER, J. L., AXD ROBERTS, J. M.:<br />
Use <strong>of</strong> <strong>the</strong> electromyogram <strong>in</strong> evahlat<strong>in</strong>g upper-es-<br />
tremity peripheral nerve lesions. J. Bone Jo<strong>in</strong>t Surg.<br />
[-imer.], 1962, 44-A, 1047.<br />
4. MaRIN.4CC1, 8. -4.. ASD COPRVILLE. C. B.: ‘Elcctrom>-o-<br />
gram <strong>in</strong> evaluation <strong>of</strong> neurological complicaiions <strong>of</strong><br />
sp<strong>in</strong>al anes<strong>the</strong>sia. J.A.M.A., 1958, 168, 1337.<br />
5. Joz~ssor;, E. W., ASD OLSES~ I(. J.: Cl<strong>in</strong>ical vnluc <strong>of</strong><br />
motor nerve conduction velority dcterm<strong>in</strong>ntion.<br />
Ibid., 1960, 172,203O.