Fixed-Dose Triple Combination of Antihypertensive Drugs Improves Blood Pressure Control: From Clinical Trials to Clinical Practice

The future of hypertension pharmacotherapy: Ongoing and future clinical trials for hypertension

Hypertension is among the most prevalent diagnoses across the world and increases the risk of many serious health problems, such as stroke, heart disease, and kidney disease. Pharmacological approaches to treat hypertension are often required and reduce blood pressure through mechanisms such as vasodilation, inhibition of the renin-angiotensin-aldosterone pathway, and increased urine output to reduce blood volume, among other mechanisms. Further research is ongoing to find novel pathways and mechanisms to treat hypertension, which we summarize in this review. We used clinicaltrials.gov to gather information about ongoing clinical trials of pharmacological hypertension therapy as of March 2024 and found 103 clinical trials that met our criteria. The interventions of these 103 clinical trials include novel and previously approved pharmacological and dietary supplement therapies for hypertension. We aim to use these clinical trials to provide insight into the future therapies and practices of hypertension treatment.

Impact of single-pill combinations versus free-equivalent combinations on adherence and persistence in patients with hypertension and dyslipidemia: a systematic literature review and meta-analysis

OBJECTIVES

Hypertension is a leading cause of death and disease burden followed by dyslipidemia. Their asymptomatic nature leads to low adherence and persistence to treatments. A systematic literature review (SLR) investigated the impact of single-pill-combinations (SPC) compared to free-equivalent combination (FEC) on adherence, persistence, clinical outcomes, healthcare resource utilization (HCRU), and patient-reported outcomes, in patients with hypertension, dyslipidemia, or both.

METHODS

MEDLINE, MEDLINE-IN-PROCESS, Embase, and Cochrane were searched from inception until 11 May 2021, for studies comparing SPC against FEC in patients with hypertension and/or dyslipidemia. Patient characteristics, study design, therapies, measures of adherence or persistence, clinical outcomes, and follow-up were extracted.

RESULTS

Among 52 studies identified in the SLR, 27 (n = 346,030 patients) were included in the meta-analysis. SPCs were associated with significantly improved adherence compared with FEC, as assessed through medication-possession-ratio ≥80% (odds ratio (OR) 0.42, p < 0.01) and proportion of days covered ≥80% (OR 0.45, p < 0.01). SPC also improved persistence (OR 0.44, p < 0.01) and systolic blood pressure (SBP) reduction (mean difference -1.50, p < 0.01) compared with the FEC.

CONCLUSIONS

SPC use resulted in significantly improved adherence, persistence, and SBP levels compared with FEC in patients with hypertension. The findings support SPC use in reducing the burden of hypertension and dyslipidemia.

Efficacy and safety of a single-pill versus free combination of perindopril/indapamide/amlodipine: a multicenter, randomized, double-blind study in Chinese patients with hypertension

BACKGROUND

In China, the prevalence of hypertension is high and the use of combination antihypertensive therapy is low, which contributes to inadequate blood pressure (BP) control. The availability of simplified treatments combining complementary BP-lowering agents may help more patients achieve their goals.

METHODS

This Phase III, multicenter, randomized, double-blind, noninferiority study included Chinese adults with mild-to-moderate hypertension. Following a 1-month run-in on perindopril/indapamide bi-therapy, patients with uncontrolled systolic/diastolic BP (≥140/90 mmHg) were randomized to perindopril 5 mg/indapamide 1.25 mg/amlodipine 5 mg (Per/Ind/Aml) single-pill combination (SPC) or perindopril 4 mg/indapamide 1.25 mg plus amlodipine 5 mg (Per/Ind + Aml) for 6 months. Uptitration was permitted from month 2 onwards. The primary efficacy objective was the noninferiority of Per/Ind/Aml in lowering office systolic BP at 2 months. The secondary objectives included the effectiveness of SPC on diastolic BP, uptitration efficacy, and office BP control (systolic/diastolic <140/90 mmHg). A subgroup of patients participated in 24-h ambulatory BP monitoring (ABPM).

RESULTS

A total of 532 patients were randomized: Per/Ind/Aml ( n  = 262) and Per/Ind + Aml ( n  = 269). Overall, the mean (±SD) age was 55.7 ± 8.8 years, 60.7% were male, and the mean office systolic/diastolic BP at baseline on Per/Ind was 150.4/97.2 mmHg. Systolic BP decreased in both groups at 2 months from baseline: -14.99 ± 14.46 mmHg Per/Ind/Aml versus -14.49 ± 12.87 mmHg Per/Ind +Aml. A predefined noninferiority margin of 4 mmHg was observed ( P  < 0.001). The effectiveness of the Per/Ind/Aml SPC was also demonstrated for all secondary endpoints. ABPM demonstrated sustained BP control over 24 h. Both treatments were well tolerated.

CONCLUSIONS

Per/Ind/Aml is an effective substitute for Per/Ind + Aml, providing at least equivalent BP control over 24 h in a single pill, with comparable safety.

Comparing Triple Combination Drug Therapy and Traditional Monotherapy for Better Survival in Patients With High-Risk Hypertension: A Systematic Review

High-risk hypertension patients are more susceptible to cardiovascular disease, stroke, and mortality. Monotherapy and triple combination drug therapy are two different approaches to treating hypertension. Monotherapy involves using a single medication to manage hypertension, whereas triple combination therapy involves the simultaneous use of three different antihypertensive medications from different drug classes. Making a fast switch from monotherapy to combination medication is one method to regulate blood pressure (BP) better. It is widely recognized that a significant proportion of individuals with hypertension require combination therapy to manage their condition effectively. This review aims to evaluate the mortality rates across monotherapy and triple combination drug therapy in high-risk hypertension patients. A systematic literature review was conducted across multiple scientific literature repositories. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines for systematic reviews and meta-analyses. Based on the end outcome of each published journal on the effectiveness of triple combination drug therapy as a treatment option for high-risk hypertension patients, there was a notable difference in overall survival, mortality rates, BP reduction, and adherence datasets. Triple combination drug use correlated with increased timeframes for multiple patient survival parameters within the articles shortlisted in this investigation. However, it is crucial for healthcare providers to weigh the risks and benefits of triple combination drug therapy when deciding which treatment approach is best for their patients.

Single-pill fixed-dose drug combinations to reduce blood pressure: the right pill for the right patient

Arterial hypertension is one of the major causes of cardiovascular morbidity and mortality worldwide. Effective and sustained reduction in blood pressure is essential to reduce individual cardiovascular risk. In daily clinical practice, single-pill fixed-dose combinations of different drug classes are important therapeutic resources that could improve both treatment adherence and cardiovascular risk management by targeting distinct pathophysiological mechanisms. The aim of this practical narrative review is to help physicians choosing the right single-pill fixed-dose combination for the right patient in the daily clinical practice, based on the individual clinical phenotype and cardiovascular risk profile.

Use of Perindopril Arginine/Indapamide/Amlodipine in the Management of Hypertension in Two Sub-Saharan African Island Countries of Madagascar and Mauritius

INTRODUCTION

Most patients with hypertension in sub-Saharan Africa require two or more drugs to control their blood pressure. Triple fixed-dose combination therapy of perindopril arginine/indapamide/amlodipine is more effective in lowering blood pressure, offers better target organ protection and has increased adherence compared to monotherapy and free combination therapy, and is safe to use. This observational study evaluates the effectiveness of perindopril arginine/indapamide/amlodipine in controlling blood pressure at least 1 month after treatment initiation and assesses patient- and physician- reported drug tolerance over a 3-month period in Madagascar and Mauritius.

METHODS

A total of 198 patients with hypertension in ambulatory care who had been on fixed-dose combination of perindopril arginine, indapamide, and amlodipine for at least 4 weeks were included. The main outcome measures were changes in systolic and diastolic blood pressure, attainment of blood pressure control under 140/90 mmHg and 130/80 mmHg, self-reported drug tolerance by the patient, and perceived drug tolerance by the treating physician. Data was collected at 1 month and 3 months.

RESULTS

Mean systolic blood pressure was significantly lower at the 1-month (- 3.4 mmHg, p = 0.002) and 3-month (- 8.5 mmHg, p < 0.0001) visits. Diastolic blood pressure also decreased significantly (- 2.4 mmHg at 1-month, p = 0.017 and - 5.4 mmHg at the 3-month visits, p < 0.0001). At 3 months, 80.4% of the patients attained blood pressure targets less than 140/90 mmHg and 42.7% attained targets less than 130/80 mmHg on the basis of their baseline blood pressure. Excellent drug tolerance was reported by more than 90% of patients and physicians at the 1-month visit and by more than 95% at the 3-month visit.

CONCLUSION

Triple fixed-dose therapy of perindopril arginine/indapamide/amlodipine continues to show additional blood pressure-lowering capacity even months after initiating the treatment in patients with hypertension in Madagascar and Mauritius. It is also well tolerated by patients with hypertension and assessed as safe to use by physicians.

Efficacy of Single-Pill, Triple Antihypertensive Therapy in Patients with Uncontrolled Hypertension: A Systematic Review and Meta-analysis

INTRODUCTION

Systemic arterial hypertension is the most common preventable risk factor for all causes of morbidity and mortality worldwide with a prevalence of 35-40% of the adults. Despite the wide variety of effective antihypertensive medications, most hypertensive patients remain uncontrolled. However, the combination of ACE inhibitor, diuretics, and calcium antagonist for the triple therapy in a single Pill Combination (SPC) is an efficient regimen in hypertension management. It is recommended by the ESH 2018 guideline, which offers better efficacy and compliance to treatment.

AIM

To evaluate the efficacy of perindopril/indapamide/amlodipine single-pill combination in patients with uncontrolled hypertension.

METHODS

We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL for relevant clinical trials. We conducted the risk of bias assessment using Cochrane's risk of bias tool. We performed the analysis of continuous data using mean difference (MD) and relative 95% confidence interval (CI), while dichotomous data were analyzed using risk ratio (RR) and relative 95% CI. We included the analysis of the following outcomes: systolic blood pressure (SBP), Diastolic blood pressure (DBP), Heart rate (HR), 24 h Ambulatory blood pressure monitoring (ABPM) for SBP, and 24 h ABPM for DBP.

RESULTS

We included six clinical trials. We found that the triple therapy significantly reduces SBP by 24 mmHg (MD = - 24.65 [22.41, 26.89], (P < 0.01)), DBP by 12 mmHg (MD = 12.41 [11.53, 13.29], (P < 0.01)), 24-h ABPM for SBP by 14 mmHg (MD = 14.08 [9.10, 19.05], (P < 0.01)), and ABPM 24 h DBP by 7 mmHg (MD = 7.01 [5.37, 8.65], (P < 0.01)). We noted no significant difference of the single pill on heart rate (MD = 0.81 [- 0.04, 1.67], (P = 0.06).

CONCLUSION

perindopril/indapamide/amlodipine is effective in reducing systolic and diastolic blood pressures by 24 and 12 mmHg respectively. Over 24 h, the combination reduced systolic and diastolic blood pressures by 14 and 7 mmHg respectively.

Perindopril/Indapamide/Amlodipine in Hypertension: A Profile of Its Use

The single-pill combination (SPC) of perindopril (PER)/indapamide (IND)/amlodipine (AML) is a valuable and convenient treatment option for patients with hypertension controlled with two-drug SPC of PER/IND + AML given as two separate pills at the same dose level. PER [an angiotensin-converting enzyme (ACE) inhibitor], IND (a thiazide-like diuretic) and AML (a calcium channel blocker) are well established antihypertensive agents, which have been available for a long time as monotherapies and dual SPCs and have complementary mechanisms of action. Once-daily PER/IND/AML provided effective BP control, with good tolerability, in patients with uncontrolled hypertension in clinical trials and in large observational prospective studies. The efficacy and tolerability of PER/IND/AML was similar to that of PER/IND + AML in a randomized clinical trial. The therapeutic effect of PER/IND/AML was associated with improved health-related quality of life. Thus, switching from the two-pill PER/IND + AML regimen to single-pill PER/IND/AML reduces pill burden and simplifies drug administration, which may improve adherence to treatment, leading to better BP control and clinical outcomes.

The Number of Pills, Rather Than the Type of Renin-Angiotensin System Inhibitor, Predicts Ambulatory Blood Pressure Control in Essential Hypertensives on Triple Therapy: A Real-Life Cross-Sectional Study

Introduction

We evaluated the prevalence and predictors of ambulatory blood pressure (BP) control in patients taking a triple antihypertensive therapy (renin–angiotensin system inhibitor + calcium channel blocker + thiazide/thiazide-like diuretic, in either free or fixed-dose combinations) containing an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB).

Methods

We performed an observational cross-sectional study on 520 consecutive patients with essential hypertension taking a stable triple therapy in whom 24-h ambulatory BP was evaluated. Both number of pills and antihypertensive treatment intensity (ATI), as possible pharmacological predictors of ambulatory BP control, were taken into account.

Results

A total of 189 (36.3%) patients were taking triple therapy with ACEi and 331 (63.7%) patients were taking triple therapy with ARB. Mean age was 62.7 ± 12.2 years. Patients on triple therapy with ACEi had a significantly lower ATI and took fewer antihypertensive pills than patients on triple therapy with ARB (22.2% of patients took a single-pill triple fixed-dose combination). Patients taking triple therapy with ACEi had higher prevalence of both 24-h (54.8% vs 44.0%; p = 0.019) and daytime BP control (61.8% vs 49.2%; p = 0.006) than patients taking triple therapy with ARB, even after adjusting for age, sex, body mass index, smoking habit, type 2 diabetes mellitus, estimated glomerular filtration rate, and ATI [OR 1.5 (95% CI 1.1–2.2) and OR 1.6 (95% CI 1.1–2.4), respectively]. However, these independent associations with ambulatory BP control were lost when the number of antihypertensive pills was included in the model.

Conclusion

The higher prevalence of ambulatory BP control found in patients taking a triple therapy with ACEi was affected by the lower number of antihypertensive pills taken, which was also the key predictor of ambulatory BP control in our study. This confirms the importance of fixed-dose combinations in the management of essential hypertension.

Perindopril Reduces Arterial Pressure and Does Not Inhibit Exercise-Induced Angiogenesis in Spontaneously Hypertensive Rats

ABSTRACT

Sympathetic activity, arteriolar structure, and angiogenesis are important mechanisms modulating hypertension and this study aimed to analyze the effects of perindopril treatment, associated or not with exercise training, on the mechanisms that control blood pressure (BP) in hypertensive rats. Spontaneously hypertensive rats (SHR) were allocated into 4 groups: 1/sedentary (S); 2/perindopril (P, 3.0 mg/kg/d); 3/trained (T); and 4/trained + perindopril (TP). Wistar rats were used as normotensive sedentary control group. SHR were assigned to undergo a treadmill training (T) or were kept sedentary. Heart rate, BP, sympathetic activity to the vessels (LF-SBP), and skeletal muscle and myocardial morphometric analyses were performed. BP was significantly lower after all 3 strategies, compared with S and was accompanied by lower LF-SBP (-76%, -53%, and -44%, for P, T, and TP, respectively). Arteriolar vessel wall cross-sectional area was lower after treatments (-56%, -52%, and -56%, for P, T, and TP, respectively), and only TP presented higher arteriolar lumen area. Capillary rarefaction was present in soleus muscle and myocardium in S group and both trained groups presented higher vessel density, although perindopril attenuated this increase in soleus muscle. Although myocyte diameter was not different between groups, myocardial collagen deposition area, higher in S group, was lower after 3 strategies. In conclusion, we may suggest that perindopril could be an option for the hypertensive people who practice exercise and need a specific pharmacological treatment to reach a better BP control, mainly because training-induced angiogenesis is an important response to facilitate blood flow perfusion and oxygen uptake and perindopril did not attenuate this response.

Adherence to Single-Pill Versus Free-Equivalent Combination Therapy in Hypertension: A Systematic Review and Meta-Analysis

Poor adherence to antihypertensive therapy is a major cause of poor blood pressure (BP) control in patients with hypertension. Regimen simplification may improve adherence and BP control. This systematic review assessed whether single-pill combination (SPC) therapy led to improved adherence, persistence, and better BP control compared with free-equivalent combination (FEC) therapy in patients with hypertension. PubMed, Medline, Embase, and the Cochrane Library were searched until July 2020, in addition to manual searching of relevant congress abstracts from 2014 to 2020 for studies including adults with hypertension aged ≥18 years receiving SPC or FEC antihypertensive therapy measuring any of the following: adherence, persistence, and reductions in systolic BP and/or diastolic BP. Adherence and persistence were summarized in a narrative analysis; direct pair-wise meta-analysis was conducted to compare BP reductions with SPC therapy versus FEC therapy using fixed-effect and random-effects models. Following screening, 44 studies were included. The majority (18 of 23) of studies measuring adherence showed adherence was significantly improved in patients receiving SPCs versus FECs. Overall, 16 studies measured persistence, of which 14 showed that patients receiving SPCs had significantly improved persistence or were significantly less likely to discontinue therapy than patients receiving FECs. Systolic BP (mean difference, -3.99 [95% CI, -7.92 to -0.07]; P=0.05) and diastolic BP (-1.54 [95% CI, -2.67 to -0.41]; P=0.0076) were both significantly reduced with SPC therapy compared with FEC therapy at week 12. SPC therapy leads to improved adherence and persistence compared with FEC therapy and may lead to better BP control in patients with hypertension.

Risk of Cardiovascular Outcomes and Antihypertensive Triple Combination Therapy Among Elderly Patients with Hypertension Enrolled in a Medicare Advantage Plan (MAP)

OBJECTIVES

The aim was to evaluate the risk of cardiovascular-specific hospitalizations with different types of antihypertensive triple combination therapy among patients enrolled in a Medicare Advantage Plan (MAP).

METHODS

A retrospective cohort study was conducted among patients with hypertension enrolled in a Texas MAP between January 2014 and December 2016. Antihypertensive combination therapy users were classified into three treatment groups: single-pill triple combination, fixed-dose dual combination plus a third agent, and free triple combination. Group differences were assessed using Chi-square tests for binary variables and Student's t tests for continuous variables. Cox proportional hazards model was performed to assess the association between type of combination therapy and risk of cardiovascular-specific hospitalization adjusting for potential confounders.

RESULTS

A total of 10,836 triple combination users were identified. The risk of cardiovascular disease (CVD) hospitalization for the fixed-dose dual combination plus a third agent group [hazard ratio (HR) 3.82, 95% confidence interval (CI) 1.80-8.12] and for the free triple combination therapy group (HR 3.65, 95% CI 1.43-9.31) was significantly higher than for the single-pill triple combination group.

CONCLUSION

Single-pill triple combination therapy was significantly associated with a lower risk of CVD hospitalizations in comparison to other types of triple combination therapy.

Single Pill Regimen Leads to Better Adherence and Clinical Outcome in Daily Practice in Patients Suffering from Hypertension and/or Dyslipidemia: Results of a Meta-Analysis

Introduction

Cardiovascular diseases (CVD) represent the first cause of mortality in western countries. Hypertension and dyslipidemia are strong risk factors for CVD, and are prevalent either alone or in combination. Although effective substances for the treatment of both factors are available, there is space for optimization of treatment regimens due to poor patient’s adherence to medication, which is usually a combination of several substances. Adherence decreases with the number of pills a patient needs to take. A combination of substances in one single-pill (single pill combination, SPC), might increase adherence, and lead to a better clinical outcome.

Aim

We conducted a meta-analysis to compare the effect of SPC with that of free-combination treatment (FCT) in patients with either hypertension, dyslipidemia or the combination of both diseases under conditions of daily practice.

Methods

Studies were identified by searching in PubMed from November 2014 until February 2015. Search criteria focused on trials in identical hypertension and/or dyslipidemia treatment as FCT therapy or as SPC. Adherence and persistence outcome included proportion-of-days-covered (PDC), medication possession ratio (MPR), time-to treatment gap of 30 and 60 days and no treatment gap of 30 days (y/n). Clinical outcomes were all cause hospitalisation, hypertension-related hospitalisation, all cause emergency room visits, hypertension-related emergency room visits, outpatient visits, hypertension-related outpatient visits, and number of patients reaching blood pressure goal. Randomized clinical studies were excluded because they usually do not reflect daily practice.

Results

11 out of 1.465 studies met the predefined inclusion criteria. PDC ≥ 80% showed an odds ratio (OR) of 1.78 (95% CI: 1.30–2.45; p = 0.004) after 6 months and an OR of 1.85 (95% CI: 1.71; 2.37; p < 0.001) after ≥ 12 months in favour to the SPC. MPR ≥ 80% after 12 months also was in favour to SPC (OR 2.13; 95% CI: 1.30; 3.47; p = 0.003). Persistence was positively affected by SPC after 6, 12, and 18 months. Time to treatment gap of 60 days resulted in a hazard ratio (HR) of 2.03 (95% CI: 1.77; 2.33, p < 0.001). The use of SPC was associated with a significant improvement in systolic blood pressure reduction, leading to a higher number of patients reaching individual blood pressure goals (FCT vs SPC results in OR = 0.77; 95% CI: 0.69; 0.85, p < 0.001). Outpatient visits, emergency room visits and hospitalisations, both overall and hypertension-related were reduced by SPC: all-cause hospitalisation (SPC vs FCT: 15.0% vs 18.2%, OR 0.79, 95% CI 0.67; 0.94, p = 0.009), all-cause emergency room visits (SPC vs FCT: 25.7% vs 31.4%, OR 0.75, 95% CI 0.65; 0.87, p = 0.001) and hypertension related emergency room visits (SPC vs FCT: 9.7% vs 14.1%, OR 0.65, 95% CI 0.54; 0.80, p < 0.001).

Conclusions

SPC improved medication adherence and clinical outcome parameter in patients suffering from hypertension and/or dyslipidemia and led to a better clinical outcome compared to FCT under conditions of daily practice.

Long-term effect of the perindopril/indapamide/amlodipine single-pill combination on left ventricular hypertrophy in outpatient hypertensive subjects

BACKGROUND

Most antihypertensive drugs used in monotherapy or in combination therapy reduce the left ventricular mass index (LVMI). However, little is known about the effects on LVMI of a triple fixed-dose combination (TFC) therapy, containing in a single pill an angiotensin-converting enzyme inhibitor (ACEI), a diuretic and a calcium channel blocker (CCB).

METHODS

In this prospective open-label study, 92 patients with essential hypertension were randomized to treatment with a TFC of perindopril/indapamide/amlodipine at different doses or a triple free combination therapy (FCT) including ACEI/diuretic/CCB. Office blood pressure (BP) measurement, 24 h-ambulatory BP monitoring and echocardiography were performed at baseline and during a 14-month follow-up. The BP variability (BPV) over 24 h was calculated as ± standard deviation of the daytime systolic BP. Differences between office and monitored BP and LVMI were evaluated by ANOVA for repeated measures.

RESULTS

A significant BP-lowering effect was observed for both treatments. At follow-up, BPV was reduced in both the treatment groups vs. the baseline (14.0±1.5 vs. 17.0±1.8 and 16.2±2.1 vs. 17.6±2.3, respectively), but it was lower in the TFC vs. the FCT group (14.0±1.5 vs. 16.1±2.2, P < 0.05). LVMI was lower in both the treatment groups, but the change was greater for TFC vs. FCT (-8.3±4.9% vs. -2.0 ±2.1%, P < 0.0001). Left ventricular hypertrophy (LVH) regression was greater in the TFC vs. the FCT group (43.5% vs. 30.4%, P < 0.05).

CONCLUSIONS

Independently of BP values achieved, the antihypertensive TFC therapy was more effective than FCT in LVMI reduction and LVH regression, possibly related to drugs' intrinsic properties and to BPV modulation.

A new strategy for taste masking on bitter drug by other combined drug in fixed-dose combination: bitterness of Amlodipine besylate could be masked efficiently by Valsartan

Objectives

The aim of this study was to evaluate the bitterness of amlodipine besylate (AML) combined with other five antihypertensive drugs: alacepril, benazepril, hydrochlorothiazide, telmisartan (TEL) and valsartan (VAL), which have possibility of usage as a fixed-dose combination (FDC) drugs.

Methods

The bitterness of individual six drugs and AML combined with each of the five drugs was evaluated using taste sensor SA402B (Intelligent Sensor Technology Inc.). AML combined with TEL or VAL was evaluated by taste sensor and human gustatory sensation tests. The interaction between AML with TEL or VAL was evaluated by 1H-NMR.

Key findings

The bitterness of AML was significantly decreased by addition of VAL, whereas it remained unchanged by the addition of TEL in taste sensor and human gustatory sensation test. In the 1H-NMR spectrum of AML with VAL, signal shifts of protons in AML were observed compared to that in AML alone. On the other hand, in the 1H-NMR spectrum of AML with TEL, signal shifts of protons in AML were not observed.

Conclusions

It was suggested that when VAL was mixed with AML, the electrostatic interactions between positive charged amino group of AML and negative charged tetrazole group of VAL were caused, and thereby led the suppression the bitterness of AML.

Antihypertensive prescription among black patients without compelling indications: prescription, effectiveness, quality and cost of medication

BACKGROUND

Hypertension remains one of the leading causes of death in Nigeria. Appropriate and cost-effective treatment of the disease is necessary to reduce mortality. This study evaluates (i) the prescription patterns and quality (ii) blood pressure control and (iii) cost of medication among patients with hypertension uncomplicated by co-morbid diseases or compelling indications.

METHOD

Patients with uncomplicated hypertension attending three clinics in the University College Hospital, Ibadan in Nigeria were recruited into this study. Information on demographics, antihypertensive medication prescribed, blood pressure measurements, and cost of medications were collected for each patient. Antihypertensive medications were classified according to the Anatomical Therapeutic Chemical (ATC) classification system and the Defined Daily Dose (DDD) system. The frequency of usage of each drug class and their prescribed doses per patient/day were calculated and compared with the DDD to assess the quality of prescription. Cost of antihypertensive medication was calculated for each patient and reported as cost per patient/day and cost per patient/month. Effect of variables on BP control was ascertained. Statistical analyses were done using SPSS, chi-square and correlation test was used to test for associations.

RESULT

A total number of 1050 hypertensive patients were included in this study. The mean age was 60 years, females made up 62% of the study population. A high level of polypharmacy (87%) and sub-optimal blood pressure control was observed. An increase in blood pressure was observed with increase in the number of medication prescribed (χ2 = 33.618, p < 0.001; r = .18, p < 0.001). The most prescribed antihypertensive medication either as a single therapy or a fixed-dose combination was diuretic. About 54% of the prescribed daily doses of antihypertensive medication exceeded the DDD. The total monthly expenditure on antihypertensive drugs was approximately N3.2 million ($15,300).

CONCLUSION

Study findings show a high level of polypharmacy and non-generic prescribing. Increased prescribing of drugs that are cost-effective, as well as prescription of fixed dose combinations (FDCs), is recommended in hypertensive patients. This is necessary to control blood pressure while increasing treatment adherence.

Cross-sectional survey evaluating blood pressure control ACHIEVEment in hypertensive patients treated with multiple anti-hypertensive agents in Belgium and Luxembourg

Objective

This study evaluates the actual blood pressure control rate and its estimation by general practitioners, the use of single-pill or free combinations, and the attitude towards single-pill combinations in primary care.

Methods

Cross-sectional observational survey in primary care between January 2015 and September 2016 in Belgium and Luxembourg. The participating general practitioners enrolled hypertensive patients taking at least 2 antihypertensive molecules (as fixed or free associations).

Results

742 general practitioners included a total of 8,006 patients, with a mean age of 66 ± 12 years. Systolic blood pressure and diastolic blood pressure were respectively 141 ± 17 mmHg and 82 ± 10 mmHg (means ± SD). These patients had a blood pressure control rate of 45%, whereas it was estimated by general practitioners to be 60%. General practitioners with 11–25 years’ experience performed better than general practitioners with 36–51 years’ experience in the evaluation of blood pressure control. Combinations used were free in 39%, single-pill in 34% and mixed in 27% of the patients. Patients receiving single-pill combinations were younger than those treated with free combinations (63 ± 12 vs. 68 ± 12 years, p < 0.001), with fewer comorbidities (39 vs. 55%, p < 0.001). In patients treated solely with free pill associations, 66% of patient cases, general practitioners were willing to switch to a single-pill combination. The main reasons were improved adherence (76%) and better blood pressure control (64%).

Conclusion

In patients requiring at least two antihypertensive drugs, blood pressure control rate remains low and is overestimated by general practitioners. Free combinations remain largely used although many general practitioners seem willing to shift to single-pill combinations. Treatment simplification could improve adherence and blood pressure control rate, which has been shown to lead to reduced morbidity and mortality.

Association Trends Between Antihypertensive Drug Therapies and Diastolic Hypotension in Emirati Patients with Type 2 Diabetes: A Single-Center Retrospective Longitudinal Study

INTRODUCTION

Diabetes mellitus (DM) is associated with multiple complications, including cardiovascular diseases. Previously, it was believed that the latter are mainly caused by hypertension and increased systolic blood pressure. However, recent studies have challenged this concept, by showing that diastolic dysfunction may also be involved in the cardiovascular events that are associated with DM. Pharmacologic management of hypertension in patients with type 2 DM appears to adversely influence diastolic function.

METHODS

Four hundred and eight medical records of hypertensive and obese Emirati patients with type 2 DM were included in the present retrospective study. The main objectives of the present study were (1) to determine the prevalence of low diastolic blood pressure (DBP) and diastolic hypotension in this group of patients and (2) to investigate the associations, if any, between the use of various antihypertensive medications and low DBP and diastolic hypotension.

RESULTS

The results of the present study showed that low DBP (< 70 mmHg) was experienced by 40% of the hypertensive type 2 DM patients, whereas diastolic hypotension (< 60 mmHg) was reported to occur in about 10% of the patients. Another important factor that has been significantly correlated with diastolic hypotension is age (p < 0.01). Association trends have been reported between low DBP and diastolic hypotension and several antihypertensive therapies, including (1) monotherapies such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), (2) dual therapies such as ACE inhibitors in combination with thiazide-like diuretics (THLDs) or beta blockers, and (3) triple therapy combinations of ACE inhibitors with THLDs and potassium-sparing diuretics.

CONCLUSION

The use of antihypertensive medications, in particular ACE inhibitors and ARBs, appears to be a risk factor for the development of low DBP and diastolic hypotension in obese hypertensive Emirati patients with type 2 DM, whereas calcium channel blockers seem to be a safer option for this group of patients.

Novel Medical Treatments for Hypertension and Related Comorbidities

Purpose of Review

The purpose of this review is to summarize the most recent data available on advances in development of novel medical treatments for hypertension and related comorbidities.

Recent Findings

Approximately half of all hypertensive patients have not achieved goal blood pressure with current available antihypertensive medications. Recent landmark studies and new hypertension guidelines have called for stricter blood pressure control, creating a need for better strategies for lowering blood pressure. This has led to a shift in focus, in recent years, to the development of combination pills as a means of achieving improved blood pressure control by increasing adherence to prescribed medications along with further research and development of promising novel drugs based on discovery of new molecular targets such as the counter-regulatory renin-angiotensin system.

Summary

Fixed-dose combination pills and novel treatments based on recently discovered pathogenic mechanisms of hypertension that have demonstrated promising results as treatments for hypertension and related comorbidities will be discussed in this review.

Antihypertensive treatment and blood pressure trends among South African adults: A repeated cross-sectional analysis of a population panel survey

BACKGROUND

Recent findings suggest a decline in mean blood pressure and prevalence of uncontrolled hypertension in the South African adult population in the last decade, in contrast with the increase previously observed. This study aimed at quantifying the contribution of antihypertensive treatment to this decline.

METHODS

We used data from the four waves of the National Income Dynamics Study between 2008 and 2015 and analysed changes in systolic (SBP) and diastolic blood pressure (DBP) and prevalence of uncontrolled hypertension among South African adults (15 years and above). We compared the observed changes with a counterfactual scenario in which the impact of antihypertensive treatment was estimated by censored regression and removed, with and without adjustment for BMI, waist circumference, alcohol use and smoking.

RESULTS

During the study period, the prevalence of antihypertensive treatment rose from 13.1% to 17.6% among women and from 5.3% to 8.2% among men. Concurrently-despite worsening trends in major biobehavioural risk factors for elevated blood pressure-mean SBP decreased in both genders, DBP decreased among women and was stable among men. The odds of uncontrolled hypertension decreased by 4%/year among women and 1%/year among men. After removing the treatment effect, the downward trend in the odds of uncontrolled hypertension was reduced to 1%/year among women and completely offset among men. Among those 55 years and older, but not among younger subjects, treatment effects also explained most of the observed decreases in mean SBP and DBP.

CONCLUSIONS

Among South African adults, we infer that diffusion of antihypertensive treatment contributed substantially to the downward trend in the prevalence of uncontrolled hypertension observed between 2008 and 2015. The marked decrease in SBP and uncontrolled hypertension found among younger participants could not be explained by treatment nor by the changing distribution of the measured risk factors available in this study, and requires further investigation.

Fixed-dose combination antihypertensive medications, adherence, and clinical outcomes: A population-based retrospective cohort study

BACKGROUND

The majority of people with hypertension require more than one medication to achieve blood pressure control. Many patients are prescribed multipill antihypertensive regimens rather than single-pill fixed-dose combination (FDC) treatment. Although FDC use may improve medication adherence, the impact on patient outcomes is unclear. We compared clinical outcomes and medication adherence with FDC therapy versus multipill combination therapy in a real-world setting using linked clinical and administrative databases.

METHODS AND FINDINGS

We conducted a population-based retrospective cohort study of 13,350 individuals 66 years and older in Ontario, Canada with up to 5 years of follow-up. We included individuals who were newly initiated on one angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II-receptor blocker (ARB) plus one thiazide diuretic. High-dimensional propensity score matching was used to compare individuals receiving FDC versus multipill therapy. The primary outcome was a composite of death or hospitalization for acute myocardial infarction (AMI), heart failure, or stroke. We conducted 2 analyses to examine the association between adherence and patient outcomes. First, we performed an on-treatment analysis to determine whether outcomes differed between groups while patients were on treatment, censoring patients when they first discontinued treatment, defined as not receiving medications within 150% of the previous days' supply. Second, we conducted an intention-to-treat analysis that followed individuals allowing for breaks in treatment to quantify the difference in drug adherence between groups and assess its impact on clinical outcomes. As expected, there was no significant difference in the primary outcome between groups in the on-treatment analysis (HR 1.06, 95% CI 0.86-1.31, P = 0.60). In the intention-to-treat analysis, the proportion of total follow-up days covered with medications was significantly greater in the FDC group (70%; IQR 19-98) than in the multipill group (42%, IQR 11-91, P < 0.01), and the primary outcome was less frequent in FDC recipients (3.4 versus 3.9 events per 100 person-years; HR 0.89, 95% CI 0.81-0.97, P < 0.01). The main limitations of this study were the lack of data regarding cause of death and blood pressure measurements and the possibility of residual confounding.

CONCLUSIONS

Among older adults initiating combination antihypertensive treatment, FDC therapy was associated with a significantly lower risk of composite clinical outcomes, which may be related to better medication adherence.

Perindopril arginine and amlodipine besylate for hypertension: a safety evaluation

INTRODUCTION

Controlling blood pressure is a global health priority; single-pill antihypertensive combinations may improve adherence, persistence, and outcomes. Areas covered: A novel combination of perindopril arginine and amlodipine besylate was recently approved. A systematic review of the literature revealed its most common adverse effects as: peripheral edema (depending on the dose of amlodipine, but attenuated by perindopril), cough, dizziness and hypotension. Dose-dependent hyperkalemia, impairment of renal function (especially in renovascular hypertension), angioedema, and teratogenicity were derived from experience with other ACE-inhibitors. Expert opinion: Substantial clinical trial experience with amlodipine or perindopril suggests that these two agents effectively lower blood pressure, and can reduce the risk of major adverse cardiovascular events, as in the Anglo-Scandinavian Cardiac Outcomes Trial. The incidence of adverse effects reported in clinical trials is lower than expected, likely due to exclusion of subjects previously exposed to its components; the nature of open-label, uncontrolled observational studies; and difficulty in recognizing and measuring cough and pedal edema. This new formulation of perindopril arginine protects its ethyl ester, without requiring physical separation from amlodipine in a single tablet, and is less hygroscopic than perindopril erbumine. These and other attributes may make this combination an attractive addition to the antihypertensive armamentarium.