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

Single-Pill Combination Therapy of Amlodipine, Telmisartan, and Chlorthalidone in the Management of Hypertension: A Systematic Review of Randomized Controlled Trials

Hypertension is a major cause of cardiovascular disease and death worldwide. Low-dose combination therapy is a promising approach for managing hypertension due to its safety and efficacy. This systematic review evaluates the safety and efficacy of a single-pill, low-dose combination of amlodipine, telmisartan, and chlorthalidone for essential hypertension based on evidence from randomized controlled trials (RCTs). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched the Cochrane, Scopus, PubMed, and Web of Science databases until July 01, 2024, using the following search string: (telmisartan) AND (amlodipine) AND (chlorthalidone) AND (randomized OR randomly). The quality of the RCTs was assessed using the revised Cochrane risk of bias tool. The primary endpoint was the mean change in sitting systolic blood pressure (BP), with secondary endpoints including BP target achievement rates, BP response rates, and serious treatment-related adverse events. Overall, three RCTs met the inclusion criteria and exhibited a low risk of bias. The doses in the combination pill ranged from 2.5 to 5 mg of amlodipine, 20 to 80 mg of telmisartan, and 4.167 to 25 mg of chlorthalidone. Control groups varied, including usual care, amlodipine 10 mg, and dual therapy of telmisartan and amlodipine. Results showed significant reductions in mean sitting systolic and diastolic BP, improved BP control and response rates, and a generally safe profile with no significant differences in serious adverse events. Despite encouraging data, results should be interpreted with caution due to heterogeneity in doses and control groups. Further research should address the long-term effects and explore predictors of response to this therapy.

Efficacy of single-pill combination in uncontrolled essential hypertension: A systematic review and network meta-analysis

This study aimed to evaluate the efficacy of single-pill combination (SPC) antihypertensive drugs in patients with uncontrolled essential hypertension. Through Searching Pubmed, EMBASE, the Cochrane Library, and Web of Science collected only randomized controlled trials on the efficacy of single-pill combination antihypertensive drugs in people with uncontrolled essential hypertension. The search period is from the establishment of the database to July 2022. The methodological quality of the included studies was assessed using the Cochrane Risk of Bias Assessment, and statistical analyses were performed using Review Manage 5.3 and Stata 15.1 software. This review ultimately included 32 references involving 16 273 patients with uncontrolled essential hypertension. The results of the network meta-analysis showed that a total of 11 single-pill combination antihypertensive drugs were included, namely: Amlodipine/valsartan, Telmisartan/amlodipine, Losartan/HCTZ, Candesartan/HCTZ, Amlodipine/benazepril, Telmisartan/HCTZ, Valsartan/HCTZ, Irbesartan/amlodipine, Amlodipine/losartan, Irbesartan/HCTZ, and Perindopril/amlodipine. According to SUCRA, Irbesartan/amlodipine may rank first in reducing systolic blood pressure (SUCRA: 92.2%); Amlodipine/losartan may rank first in reducing diastolic blood pressure (SUCRA: 95.1%); Telmisartan/amlodipine may rank first in blood pressure control rates (SUCRA: 83.5%); Amlodipine/losartan probably ranks first in diastolic response rate (SUCRA: 84.5%). Based on Ranking Plot of the Network, we can conclude that single-pill combination antihypertensive drugs are superior to monotherapy, and ARB/CCB combination has better advantages than other SPC in terms of systolic blood pressure, diastolic blood pressure, blood pressure control rate, and diastolic response rate. However, due to the small number of some drug studies, the lack of relevant studies has led to not being included in this study, which may impact the results, and readers should interpret the results with caution.

Different Doses of Scubitril/Valsartan Compared with Olmesartan in Patients with Essential Hypertension: A Systematic Review and Meta-Analysis

INTRODUCTION

Since sacubitril/valsartan (LCZ696) has neprilysin inhibition and angiotensin receptor-blocking properties, it is anticipated to have strong antihypertensive effects. However, there is not enough evidence to compare the safety and efficacy of sacubitril/valsartan to those of olmesartan in patients with hypertension.

AIM

To compare the efficacy and safety of sacubitril/valsartan versus olmesartan in patients with hypertension.

METHODS

This study follows the guidelines of the Cochrane Handbook. We searched MEDLINE, Cochrane Central, Scopus, and Web of Science databases for relevant clinical trials. We extracted outcome endpoints regarding mean ambulatory systolic/diastolic blood pressure (maSBP/maDBP), mean sitting systolic/diastolic blood pressure (msSBP/msDBP), mean ambulatory/mean sitting pulse pressure (maPP/msPP), the proportion of patients achieving blood pressure control (< 140/90 mmHg), and adverse events. We used Review Manager Software for the conduction of the analysis of this study. The effect estimates of the studies were pooled as Mean difference or risk ratio and 95% confidence interval. We also conducted a subgroup analysis based on the dose of sacubitril/valsartan.

RESULTS

A total of six clinical trials were included. The studies showed an overall low risk of bias. The pooled effect estimate revealed that sacubitril/valsartan significantly reduces maSBP, maDBP, maPP, msSBP, and msDBP measurements compared with olmesartan (p < 0.001). A significantly higher portion of patients achieved blood pressure control in the sacubitril/valsartan group (p < 0.001). The test of subgroup difference showed that 400 mg dose is significantly more effective than 200 mg dose in reducing maSBP. Regarding the safety profile, olmesartan was associated with more side effects due to drug discontinuation and more serious side effects.

CONCLUSION

Sacubitril/valsartan or LCZ696 is more effective and safer than olmesartan for controlling blood pressure in patients with hypertension.

Evaluation of the Safety and Efficacy of Dual Therapy Perindopril/Amlodipine in the Management of Hypertension. A Systematic Review and Meta-Analysis

INTRODUCTION

Hypertension represent the commonest cause of death in 2017. Hypertension is classified into two types which are primary or essential hypertension and secondary hypertension. The perindopril-amlodipine combination showed a significant effect in reduction of the elevated BP and the cardiovascular complications.

AIM

To evaluate the efficacy and safety of a fixed-dose single-pill combination of perindopril-amlodipine in hypertensive patients.

METHODS

We searched PubMed, Medline, SCOPUS, and Web of Science for relevant clinical trials. Quality appraisal was evaluated according to GRADE and we assessed the risk of bias using Cochrane's risk of bias tool. We included the following outcomes: systolic blood pressure, diastolic blood pressure, pulse pressure, mean blood pressure, heart rate, cough, dizziness, headache, and peripheral edema. We performed the analysis of homogeneous data under the fixed-effects model, while analysis of heterogeneous data was analyzed under the random-effects model. We conducted a meta-regression according to the dose.

RESULTS

We included ten clinical trials. The pooled analysis showed that there was a significant reduction of the systolic blood pressure, diastolic blood pressure, pulse plessure, mean blood pressure, and heart rate after the the perindopril-amlodipine combination (MD = 18.96 [14.32, 23.60], P < 0.0001), (MD = 11.90 [8.45, 15.35], P < 0.0001), (MD = 8.44 [6.91, 9.97], P = 0.0001), (MD = 13.07 [5.86, 20.29], P = 0.0004), and (MD = 2.93 [0.89, 4.96], P = 0.005), respectively. The results of the meta-regression revealed that the efficacy is increased by increasing the dose (P < 0.001) CONCLUSION: The use of the perindopril-amlodipine combination had a significant effect on the reduction of SBP, DBP, mean blood pressure, pulse pressure, and HR.