Achieving blood pressure goal: initial therapy with valsartan/hydrochlorothiazide combination compared with monotherapy

Efficacy and safety of valsartan compared to enalapril in hypertensive children: a 12-week, randomized, double-blind, parallel-group study

OBJECTIVE

This study compares efficacy and safety of valsartan with enalapril in hypertensive children aged 6-17 years.

METHOD

This was a 12-week, randomized, double-blind, parallel-group, active-controlled study. After a single-blind placebo run-in period (4-28 days), patients with mean sitting systolic blood pressure (BP) (MSSBP) at least 95th percentile for age, gender, and height were randomized to receive half the assigned dose for first week, and force-titrated to full dose for 11 weeks (≥18 to <35 kg - valsartan: 80 mg, enalapril: 10 mg; ≥35 to <80 kg - valsartan: 160 mg, enalapril: 20 mg; ≥80 to ≤160 kg - valsartan: 320 mg, enalapril: 40 mg). The primary efficacy variable was changed from baseline in MSSBP to show noninferiority of valsartan to enalapril. Other efficacy variables were changed from baseline in MSDBP, SBP control rate, and 24-h ambulatory BP parameters.

RESULTS

Of 300 randomized patients, 281 (94%) completed the study. At week 12, MSSBP reductions were similar for valsartan and enalapril (primary endpoint of noninferiority, P < 0.0001). Least square mean BP reductions from baseline of -15.4/-9.4 mmHg were observed for valsartan compared with -14.1/-8.5 mmHg for enalapril. A similar proportion of patients achieved SBP control (valsartan: 67%; enalapril: 70%). In the subset of patients who underwent ambulatory BP assessments, valsartan provided greater reductions than enalapril in mean 24-h SBP (valsartan: -9.8 mmHg, enalapril: -7.2 mmHg: P = 0.03). The overall incidence of AEs was similar (valsartan 60%, enalapril 58%) with headache, cough, and nasopharyngitis reported most frequently.

CONCLUSIONS

Valsartan and enalapril provided comparable BP reductions and effective BP control and were well tolerated in hypertensive children aged 6-17 years.

Efficacy, safety, and tolerability of valsartan/hydrochlorothiazide in Asian patients with essential hypertension

INTRODUCTION

Previous studies have demonstrated that hypertensive patients need concomitant therapy with one or more drugs from different classes of antihypertensive agents to achieve their blood pressure control targets. We performed the first multinational observational study of valsartan/hydrochlorothiazide (HCTZ) single pill combination in Asia to determine the efficacy, safety, and tolerability in hypertensive patients. The objective of this multinational, multicenter, 24-week follow-up observational study is to evaluate the efficacy, safety, and tolerability of valsartan/hydrochlorothiazide single pill combination in the treatment of essential hypertension in the Asia-Pacific region.

METHODS

A total of 7567 Asian patients who were diagnosed with stage 1 or stage 2 essential hypertension and who took at least one dose of valsartan/hydrochlorothiazide single pill combination were included in the statistical analyses. A total of 59% were taking antihypertensive medication at the time of the study. Eligible patients received valsartan/hydrochlorothiazide single pill combination 80/12.5 mg tablets orally once daily at visit 1. The investigator could decide the subsequent dose of valsartan/hydrochlorothiazide single pill combination for their patients, and efficacy, safety, and tolerability data were collected at week 4, 12, and 24.

RESULTS

Basal blood pressure was 155.9±13.3 mmHg (systolic) and 96.3±10.1 mmHg (diastolic). Response rates and control rates increased continuously from baseline to the study endpoint at week 24, when they reached 94.6% and 73.2%, respectively. Systolic and diastolic blood pressure reductions were -25.4±15.2 mmHg and -14.9±13.5 mmHg, respectively (P<0.001). Using a four-point global assessment scale, 96.8% of the patients and physicians reported good, very good, or excellent for both their subjective efficacy and tolerability assessments.

CONCLUSION

In this multicenter, multicountry study including 7567 Asian patients with hypertension, valsartan/hydrochlorothiazide single pill combination was found efficacious, well tolerated, and devoid of any serious adverse effects.

Clinical utility of valsartan in the treatment of hypertension in children and adolescents

Valsartan is a potent antagonist of the type 1 angiotensin receptor (AT(1)). By blocking the actions of angiotensin II on the AT(1), it inhibits vasoconstriction and synthesis of aldosterone thus lowering systemic blood pressure. Valsartan has been approved by the FDA for the treatment of hypertension in children aged 6 years and older. Valsartan can be dosed once a day with a sustained 24-hour effect on blood pressure reduction. The starting dose recommended in children is 1.3 mg/kg once daily (maximum 40 mg) which needs adjustment according to blood pressure response (dose range 1.3-2.7 mg/kg daily; up to 160 mg). A suspension form (4 mg/mL) is available for children who cannot swallow tablets. In patients aged 6 to 16 years, valsartan treatment (from a low dose of 10-20 mg to a high dose of 80-160 mg) resulted in dose-dependent reductions of 7.9-11.5 mmHg in systolic blood pressure and 4.6-7.4 mmHg in diastolic blood pressure. In 1- to 5-year-olds, valsartan (from a low dose of 5-10 mg to a high dose of 40-80 mg) reduced the systolic blood pressure by 8.4-8.6 mmHg and the diastolic blood pressure by 5.5 mmHg. Similar to adults and other antihypertensive medications, the most frequent side effect in children subsequent to valsartan use is headache. Current studies have not shown adverse effects on linear growth, weight gain, head growth, or development in children aged 1 to 5 years subsequent to valsartan use. Based on limited pediatric data, valsartan appears to be well tolerated and efficacious in reducing elevated blood pressure.

Initial combination therapy for type 2 diabetes mellitus: is it ready for prime time?

The increased prevalence of type 2 diabetes mellitus is primarily being driven by the increasing global rates of overweight/obesity. Given the magnitude of this epidemic, we can expect these metabolic abnormalities to play an increasing role in the development of cardiovascular disease. In a pathophysiologic sense, type 2 diabetes is a multiorgan, multifactorial condition, characterized by β-cell dysfunction, insulin resistance in peripheral tissues and the liver, defective incretin activity, and elevated levels of free fatty acids and proinflammatory mediators. Despite the considerable burden of disease associated with type 2 diabetes, most patients are not at, or are unable to achieve, recommended glycemic control guideline targets. In part, this is because of the relentlessly progressive nature of the disease, but it may also be attributable to the current diabetes treatment paradigm, which is characterized by ineffective lifestyle interventions, followed by monotherapy and frequent early treatment failure with prolonged periods of elevated glucose as a consequence of clinical inertia. Thus, it is most appropriate to rethink the current treatment paradigm for type 2 diabetes in the context of a more aggressive initial therapy; specifically with early initiation of combination therapy. Our current understanding of the complex pathophysiology of the disease and the progressive deterioration in glycemic control over time supports the philosophy of earlier intervention with a more comprehensive initial therapy. Thus, while control of hyperglycemia remains the paramount goal, focusing on the underlying pathophysiology of type 2 diabetes is increasingly becoming the therapeutic strategy, with the aim of potentially providing disease modification. Although this is a logical approach, it remains to be demonstrated that early combination therapy will result in disease modification in a clinical setting. Not surprisingly, the incretin-based therapies have gained a great deal of attention in the context of being a component of initial combination therapy, given their potential beneficial effects on β-cell function with lowered risk of weight gain and hypoglycemia.