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Wang JG, Topouchian J, Bricout-Hennel S, Mu J, Chen L, Li P, He S, Luo S, Jiang W, Jiang Y, Sun Y, Zhang Y, Asmar R. 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. J Hypertens 2024; 42:1373-1381. [PMID: 38660708 PMCID: PMC11216387 DOI: 10.1097/hjh.0000000000003741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/22/2024] [Accepted: 03/21/2024] [Indexed: 04/26/2024]
Abstract
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.
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Affiliation(s)
- Ji-Guang Wang
- Department of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jirar Topouchian
- Paris Descartes University, AP-HP, Diagnosis and Therapeutic Center, Hôtel-Dieu
| | | | - Jianjun Mu
- Department of Cardiology, First Affiliated Hospital, School of Medicine of Xi’an Jiaotong University, Xi’an, Shaanxi
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, Fujian
| | - Ping Li
- Department of Cardiology, Second affiliated hospital of Nanchang University, Nanchang, Jiangxi
| | - Shenghu He
- Department of Cardiology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu
| | - Suxin Luo
- Department of Cardiology, First affiliated hospital, Chongqing Medical University Chongqing
| | - Weihong Jiang
- Department of Cardiology, Third Xiangya Hospital of Central South University, Changsha, Hunan
| | - Yinong Jiang
- Department of Cardiology, First affiliated hospital of Dalian Medical University, Dalian, Liaoning
| | - Yuemin Sun
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin
| | - Yuqing Zhang
- Department of Cardiology, Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Roland Asmar
- Foundation-Medical Research Institutes, Geneva, Switzerland
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Rodgers A, Salam A, Cushman W, de Silva A, Di Tanna GL, Gnanenthiran SR, Grobbee D, Narkiewicz K, Ojji D, Oparil S, Poulter N, Schlaich MP, Schutte AE, Spiering W, Williams B, Wright JT, Whelton P. Rationale for a New Low-Dose Triple Single Pill Combination for the Treatment of Hypertension. Glob Heart 2024; 19:18. [PMID: 38371656 PMCID: PMC10870947 DOI: 10.5334/gh.1283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 12/04/2023] [Indexed: 02/20/2024] Open
Abstract
Two recent large trials showed the potential of single pill combinations (SPCs) with ≥3 low-dose components among people with hypertension who were untreated or receiving monotherapy. In both trials, these 'hypertension polypills' were superior to usual care, achieving >80% BP control without increasing withdrawal due to side effects. However, there are no such products available for prescribers. To address this unmet need, George Medicines developed GMRx2 with telmisartan/amlodipine/indapamide in three strengths (mg): 10/1.25/0.625, 20/2.5/1.25; 40/5/2.5. Two pivotal trials are ongoing to support FDA submission for the treatment of hypertension, including initial treatment. These assess efficacy and safety of GMRx2 compared to: placebo, and each of the three possible dual combinations. Regulatory submissions are planned for 2024, with the aim of providing access to GMRx2 in developed and developing regions. Wider implementation of GMRx2-based treatment strategies will be guided by further research to inform access and appropriate scale up.
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Affiliation(s)
- Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Australia
| | - Abdul Salam
- The George Institute for Global Health, University of New South Wales, India
- Prasanna School of Public Health, Manipal Academy of Higher Education, India
| | | | | | - Gian Luca Di Tanna
- University of Applied Sciences and Arts of Southern Switzerland, Switzerland
| | | | - Diederick Grobbee
- University Medical Center Utrecht, Utrecht University, The Netherlands
| | | | | | | | | | | | - Aletta E. Schutte
- The George Institute for Global Health, University of New South Wales, Australia
| | - Wilko Spiering
- University Medical Center Utrecht, Utrecht University, The Netherlands
| | | | - Jackson T. Wright
- University Hospitals Cleveland Medical Center, Case Western Reserve University, USA
| | - Paul Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, USA
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Huang QF, Zhang D, Luo Y, Hu K, Wu Q, Qiu H, Xu F, Wang ML, Chen X, Li Y, Wang JG. Comparison of two single-pill dual combination antihypertensive therapies in Chinese patients: a randomized, controlled trial. BMC Med 2024; 22:28. [PMID: 38263021 PMCID: PMC10807184 DOI: 10.1186/s12916-023-03244-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 12/28/2023] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Current hypertension guidelines recommend combination of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker with a calcium-channel blocker or thiazide diuretic as initial antihypertensive therapy in patients with monotherapy uncontrolled hypertension. However, to what extent these two different combinations are comparable in blood pressure (BP)-lowering efficacy and safety remains under investigation, especially in the Chinese population. We investigated the BP-lowering efficacy and safety of the amlodipine/benazepril and benazepril/hydrochlorothiazide dual therapies in Chinese patients. METHODS In a multi-center, randomized, actively controlled, parallel-group trial, we enrolled patients with stage 1 or 2 hypertension from July 2018 to June 2021 in 20 hospitals and community health centers across China. Of the 894 screened patients, 560 eligible patients were randomly assigned to amlodipine/benazepril 5/10 mg (n = 282) or benazepril/hydrochlorothiazide 10/12.5 mg (n = 278), with 213 and 212 patients, respectively, who completed the study and had a valid repeat ambulatory BP recording during follow-up and were included in the efficacy analysis. The primary outcome was the change from baseline to 24 weeks of treatment in 24-h ambulatory systolic BP. Adverse events including symptoms and clinically significant changes in physical examinations and laboratory findings were recorded for safety analysis. RESULTS In the efficacy analysis (n = 425), the primary outcome, 24-h ambulatory systolic BP reduction, was - 13.8 ± 1.2 mmHg in the amlodipine/benazepril group and - 12.3 ± 1.2 mmHg in the benazepril/hydrochlorothiazide group, with a between-group difference of - 1.51 (p = 0.36) mmHg. The between-group differences for major secondary outcomes were - 1.47 (p = 0.18) in 24-h diastolic BP, - 2.86 (p = 0.13) and - 2.74 (p = 0.03) in daytime systolic and diastolic BP, and - 0.45 (p = 0.82) and - 0.93 (p = 0.44) in nighttime systolic and diastolic BP. In the safety analysis (n = 560), the incidence rate of dry cough was significantly lower in the amlodipine/benazepril group than in the benazepril/hydrochlorothiazide group (5.3% vs 10.1%, p = 0.04). CONCLUSIONS The amlodipine/benazepril and benazepril/hydrochlorothiazide dual therapies were comparable in ambulatory systolic BP lowering. The former combination, compared with the latter, had a greater BP-lowering effect in the daytime and a lower incidence rate of dry cough. TRIAL REGISTRATION ClinicalTrials.gov, NCT03682692. Registered on 18 September 2018.
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Affiliation(s)
- Qi-Fang Huang
- Department of Cardiovascular Medicine, Centre for Epidemiological Studies and Clinical Trials, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Department of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Ruijin 2nd Road 197, Shanghai, 200025, China
| | - Di Zhang
- Department of Cardiovascular Medicine, Centre for Epidemiological Studies and Clinical Trials, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Department of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Ruijin 2nd Road 197, Shanghai, 200025, China
| | - Yihong Luo
- Department of Cardiology, Chongming Branch of Shanghai Tenth People's Hospital, Shanghai, China
| | - Kun Hu
- Department of Cardiology, Chongming Branch of Shanghai Tenth People's Hospital, Shanghai, China
| | - Qiong Wu
- Department of Cardiology, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Hailong Qiu
- Department of Cardiology, Suzhou Hospital of Anhui Medical University (Suzhou Municipal Hospital of Anhui Province), Suzhou, Anhui Province, China
| | - Fei Xu
- Department of Cardiology, Suzhou Hospital of Anhui Medical University (Suzhou Municipal Hospital of Anhui Province), Suzhou, Anhui Province, China
| | - Mei-Ling Wang
- Hypertension Center, Puyang People's Hospital, Puyang, Henan Province, China
| | - Xin Chen
- Department of Hypertension, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yan Li
- Department of Cardiovascular Medicine, Centre for Epidemiological Studies and Clinical Trials, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Department of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Ruijin 2nd Road 197, Shanghai, 200025, China
| | - Ji-Guang Wang
- Department of Cardiovascular Medicine, Centre for Epidemiological Studies and Clinical Trials, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Department of Hypertension, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Ruijin 2nd Road 197, Shanghai, 200025, China.
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Borghi C, Cicero AF, Agnoletti D, Fiorini G. Pathophysiology of cough with angiotensin-converting enzyme inhibitors: How to explain within-class differences? Eur J Intern Med 2023; 110:10-15. [PMID: 36628825 DOI: 10.1016/j.ejim.2023.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/30/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
Angiotensin converting enzyme inhibitors (ACEi) have consistently demonstrated improved survival and reduced risk of major cardiovascular events, across the spectrum of cardiovascular disease, including hypertension, coronary artery disease, myocardial infarction, and heart failure. The cardioprotective effects of ACEi result from inhibiting the conversion of angiotensin I to angiotensin II, and inhibition of bradykinin degradation. They are generally well tolerated but may cause the onset of a dry cough in some patients. This review presents current evidence on the incidence and mechanisms of cough associated with ACEi use, and then considers how to manage ACEi-related cough in clinical practice. The incidence of ACEi-induced cough in the published literature varies widely due to heterogeneity in the source data and lack of adequate controls. Incidence also varies among individual ACEi with agents such as perindopril, which has a high tissue ACE affinity, associated with a lower rate of cough. Evidence from real-world studies shows that the incidence of ACEi-associated cough is lower than rates reported in clinical trials. Patients who experience any dry cough are often switched to angiotensin- receptor blockers or other classes of antihypertensive drugs, regardless of cough severity. To avoid inappropriate discontinuation of ACEi in clinical practice, an alternative approach in patients with persistent cough is to perform a challenge/re-challenge to determine if re-introduction of ACEi is associated with recurrence of symptoms. Incidence of cough should not be considered a class effect for ACEi, and the patient may benefit by a switch from one ACEi to another. Every effort should be made to enable patients to continue ACEi therapy to reduce adverse cardiovascular outcomes and improve survival.
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Affiliation(s)
- Claudio Borghi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy.
| | - Arrigo Fg Cicero
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Davide Agnoletti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
| | - Giulia Fiorini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna 40138, Italy
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Use of Perindopril Arginine/Indapamide/Amlodipine in the Management of Hypertension in Two Sub-Saharan African Island Countries of Madagascar and Mauritius. Adv Ther 2022; 39:2850-2861. [PMID: 35438448 PMCID: PMC9122888 DOI: 10.1007/s12325-022-02134-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/16/2022] [Indexed: 11/03/2022]
Abstract
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.
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Habboush S, Sofy AA, Masoud AT, Cherfaoui O, Farhat AM, Abdelsattar AT, Elmoursi A. Efficacy of Single-Pill, Triple Antihypertensive Therapy in Patients with Uncontrolled Hypertension: A Systematic Review and Meta-analysis. High Blood Press Cardiovasc Prev 2022; 29:245-252. [PMID: 35325410 DOI: 10.1007/s40292-022-00511-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 03/04/2022] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Ahmed Elmoursi
- Department of Internal Medicine, College of Medicine, University of Kentucky, 800 Rose St, Lexington, KY, 40508, USA.
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Perindopril/Indapamide/Amlodipine in Hypertension: A Profile of Its Use. Am J Cardiovasc Drugs 2022; 22:219-230. [PMID: 35257306 PMCID: PMC8964631 DOI: 10.1007/s40256-022-00521-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 11/01/2022]
Abstract
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.
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Milošević M, Otašević P. Treatment-resistant hypertension. ARHIV ZA FARMACIJU 2022. [DOI: 10.5937/arhfarm72-34248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Treatment-resistant hypertension is one of the most significant causes of poor blood pressure regulation. Patients with resistant hypertension are at a higher risk of developing comorbidities compared to the general hypertensive population. As a result, these patients have an increased incidence of disability and premature death, as well as increased treatment costs. Due to the above-mentioned, in the last decade, there has been an increase in researchers' interest in elucidating the pathogenesis, diagnosis, and treatment of resistant hypertension. However, recent data indicate that 20% of female and 24% of male patients with arterial hypertension still have uncontrolled blood pressure, despite maximum doses of three antihypertensive drugs (including a diuretic) and appropriate lifestyle measures. New treatment modalities (i.e. devicebased interventions - catheter-based renal denervation and baroreceptor stimulation) offer hope for achieving adequate blood pressure regulation in these patients. In this paper, we have summarized previous knowledge about the mechanisms underlying the pathogenesis of resistant hypertension, as well as optimal diagnostic methods to differentiate true from pseudo-resistant hypertension. We have also given an overview of the current therapeutic approach, including optimal medical therapy and new treatment modalities (i.e. device-based interventions) and their role in the treatment of resistant hypertension.
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Sarzani R, Giulietti F, Filipponi A, Marziali S, Ristori L, Buscarini S, Garbuglia C, Biondini S, Allevi M, Spannella F. 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. Adv Ther 2021; 38:4013-4025. [PMID: 34115328 PMCID: PMC8279975 DOI: 10.1007/s12325-021-01799-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 05/18/2021] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Riccardo Sarzani
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS INRCA, Ancona, Italy.
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy.
| | - Federico Giulietti
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Andrea Filipponi
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Sonia Marziali
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Letizia Ristori
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Silvia Buscarini
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Caterina Garbuglia
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Simone Biondini
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Massimiliano Allevi
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Francesco Spannella
- Internal Medicine and Geriatrics, "Hypertension Excellence Centre" of the European Society of Hypertension, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
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Tsioufis K, Kreutz R, Sykara G, van Vugt J, Hassan T. Impact of single-pill combination therapy on adherence, blood pressure control, and clinical outcomes: a rapid evidence assessment of recent literature. J Hypertens 2021; 38:1016-1028. [PMID: 32371789 PMCID: PMC7253190 DOI: 10.1097/hjh.0000000000002381] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The 2018 European Society of Cardiology/European Society of Hypertension Guidelines for the management of arterial hypertension raised the need for evidence to support the use of single-pill combination (SPC) therapy in preference to free-dosed therapy for hypertension. This systematic rapid evidence assessment sought to determine if initiating SPC therapy improves adherence, blood pressure (BP) control and/or cardiovascular outcomes vs. initiation of free-dose combination therapy.
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Affiliation(s)
- Konstantinos Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Reinhold Kreutz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - Georgia Sykara
- Medical Affairs, Pfizer Upjohn Hellas Ltd, Athens, Greece
| | - Joris van Vugt
- Medical Affairs, Pfizer Upjohn, Cappelle a/d Ijssel, The Netherlands
| | - Tarek Hassan
- Medical Affairs, Pfizer Upjohn, New York, New York, USA
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11
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An J, Derington CG, Luong T, Olson KL, King JB, Bress AP, Jackevicius CA. Fixed-Dose Combination Medications for Treating Hypertension: A Review of Effectiveness, Safety, and Challenges. Curr Hypertens Rep 2020; 22:95. [DOI: 10.1007/s11906-020-01109-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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12
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Pinto B, Jadhav U, Singhai P, Sadhanandham S, Shah N. ACEI-induced cough: A review of current evidence and its practical implications for optimal CV risk reduction. Indian Heart J 2020; 72:345-350. [PMID: 33189192 PMCID: PMC7670268 DOI: 10.1016/j.ihj.2020.08.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/20/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023] Open
Abstract
Cough is one of the common adverse effects in patients receiving angiotensin-converting enzyme inhibitors (ACEIs). This review presents the current evidence on incidence and mechanisms of cough associated with ACEIs use, and proposes a practical approach for managing the same for optimal cardiovascular (CV) risk reduction. The incidence of dry cough in patients receiving ACEIs vary among individual ACEIs, and is the lowest with perindopril. Cough is thought to originate from multiple mechanisms, bradykinin theory is the most commonly appealed hypothesis. The strategies for optimal management could be temporarily discontinuation of ACEI upon a reported incidence of cough and reintroduction after its remission. However, studies have reported disappearance of cough despite continuing treatment. Another important approach could be adding calcium channel blockers to ACEIs. Switching to alternative drugs such as angiotensin receptor blockers should be suggested in case intolerable symptoms recur and after exclusion of all other possible causes of cough.
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Affiliation(s)
- Brian Pinto
- Holy Family Hospital, Bandra, Director-Cardiac Catheterization Laboratory, India.
| | | | | | | | - Nishita Shah
- Serdia Pharmaceuticals (India) Pvt Ltd., Mumbai, Maharashtra, India
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13
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Efficacy and safety of triple versus dual combination blood pressure-lowering drug therapy: a systematic review and meta-analysis of randomized controlled trials. J Hypertens 2020; 37:1567-1573. [PMID: 31058799 DOI: 10.1097/hjh.0000000000002089] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Most patients with hypertension need at least two drugs to achieve goal blood pressure. This systematic review assessed efficacy and safety of triple versus dual combination therapy for the management of hypertension. METHODS Publication databases, clinical trial registries and regulatory agency websites were searched until April 2018 for double-blind randomized controlled trials (RCTs) comparing triple with dual therapy of BP-lowering drugs, for at least 3 weeks, among patients with hypertension. Meta-analyses for efficacy and safety outcomes were performed using random-effects model. Regimen efficacy was predicted using the Therapeutic Intensity Score (TIS) and the Law et al. method (which predict dose doubling increases efficacy by 100% and around 20%, respectively), and compared with observed efficacy. RESULTS Fourteen RCTs (11 457 participants) were included. Overall, triple compared with dual therapy reduced BP by 5.4/3.2 mmHg (P < 0.001), and improved BP control by 58 versus 45% [relative risk (RR) 1.33 (95% CI 1.25-1.41)], whereas incidence of withdrawals because of adverse events were 3.3 versus 3.4% [RR 1.24 (95% CI 1.00-1.54), P = 0.05]. Law et al.'s method was superior to TIS in predicting differences in efficacy between triple and dual therapies. For patients uncontrolled on submaximal dose dual therapy, adding a third drug achieved on average approximately four times more BP reduction than doubling the dose of dual therapy component drugs (6.0/3.6 versus 1.5/0.8 mmHg, respectively). CONCLUSION Addition of a third drug is likely to be more efficacious without increasing adverse events, compared with increasing dose of existing dual therapy. Early use of triple therapy can significantly improve hypertension control.
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Reply. J Hypertens 2020; 38:777. [PMID: 32132437 DOI: 10.1097/hjh.0000000000002389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Feasibility of 24-h central blood pressure monitoring: experience from multinational clinical trial assessing the efficacy of perindopril/indapamide/amlodipine. J Hypertens 2019; 37:2442-2451. [PMID: 31343543 DOI: 10.1097/hjh.0000000000002199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Brachial blood pressure (BP) is a predictor of cardiovascular events. Evidence suggests that central BP (CBP) provides additional information for cardiovascular risk assessment. Methods to assess 24-h CBP are now available. Our objective was to assess the feasibility of 24-h CBP monitoring in clinical trials and its ability for drug evaluation. METHODS Data are issued from an international phase 3 randomized clinical trial comparing the efficacy of perindopril/indapamide/amlodipine vs. perindopril/indapamide (Per/Ind), in uncontrolled hypertensive patients treated with Per/Ind. 24-h ambulatory BP monitoring (ABPM) was performed at baseline and after 1-month treatment using the Mobil-O-Graph device which provide brachial BP and CBP and arterial parameters. RESULTS From the 345 patients included in the ABPM substudy, 276 had two valid ABPM (M0 and M1) for brachial BP assessment (80%). After applying device/software built-in and expert quality control criteria on these recordings, 210 (76%) had valid data at M0 and M1 for the assessment of CBP. After 1 month, superior ambulatory central SBP reductions were observed in the perindopril/indapamide/amlodipine (n = 101) vs. Per/Ind group (n = 109) for 24-h/daytime/night-time periods (-4.5 mmHg, P = 0.002/-5.0, P < 0001/-4.1 mmHg, P = 0.016, respectively). Similar trends were observed for pulse wave velocity and other central parameters. CONCLUSION Recording 24-h central ABPM and its derived arterial parameters needs a strict expert quality control and must consider a loss of up to 39% of the population included in the ABPM substudy. This method can be used to assess drug effect.
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Tsioufis K, Douma S, Kallistratos MS, Manolis AJ. Effectiveness and Adherence to Treatment with Perindopril/Indapamide/Amlodipine Single-Pill Combination in a Greek Population with Hypertension. Clin Drug Investig 2019; 39:385-393. [PMID: 30790132 DOI: 10.1007/s40261-019-00761-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Despite the overwhelming evidence and the established benefits of antihypertensive treatment, adherence to treatment remains low. OBJECTIVE To assess the adherence to treatment with a perindopril/indapamide/amlodipine single-pill combination (SPC), its effectiveness on blood pressure (BP) reduction, as well as the safety and tolerability of this SPC over a 4-month treatment period. METHODS This multicenter, non-interventional study prospectively included 2285 hypertensive patients on perindopril/indapamide/amlodipine SPC. The data were recorded at baseline, 1 month, and 4 months. RESULTS Of the 2285 hypertensive patients included in the study, 50.5% were at "high/very high risk". Mean systolic (SBP)/diastolic (DBP) decreased from 162.3 ± 13.3/93.1 ± 9.3 mmHg at baseline to 129.7 ± 8.3/78.6 ± 7.1 mmHg at 4 months (p < 0.001). Patients with higher baseline BP levels showed greater BP reduction. Patients with hypertension stages 1, 2, and 3 showed mean SBP/DBP reductions of 21.5/10.4 mmHg, 34.2/14.7 mmHg, and 51.2/22.5 mmHg, respectively, at study end (p < 0.001). Only 26 patients (1.1%) prematurely discontinued treatment (0.58% due to an adverse reaction or event). CONCLUSIONS Perindopril/indapamide/amlodipine SPC decreased BP levels rapidly and significantly. The degree of BP reduction was associated with the severity of hypertension and/or with total cardiovascular risk at baseline. Simplifying the drug regimen by using this SPC improved adherence and showed excellent tolerability.
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Affiliation(s)
- Kostas Tsioufis
- 1st Cardiology Clinic, "Hippokration" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stella Douma
- 3rd Department of Internal Medicine, "Papageorgiou Hospital", Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Manolis S Kallistratos
- Cardiology Department, Asklepieion General Hospital, 1 Vasileos Pavlou Ave, Voula, 16673, Athens, Greece.
| | - Athanasios J Manolis
- Cardiology Department, Asklepieion General Hospital, 1 Vasileos Pavlou Ave, Voula, 16673, Athens, Greece
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Gorostidi M, de la Sierra A. Combination therapies for hypertension – why we need to look beyond RAS blockers. Expert Rev Clin Pharmacol 2018; 11:841-853. [DOI: 10.1080/17512433.2018.1509705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Manuel Gorostidi
- Department of Nephrology, Hospital Universitario Central de Asturias, RedinRen, Oviedo, Spain
| | - Alejandro de la Sierra
- Department of Internal Medicine, Hospital Mutua Terrassa, University of Barcelona, Barcelona, Spain
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Elliott WJ, Bistrika EA. Perindopril arginine and amlodipine besylate for hypertension: a safety evaluation. Expert Opin Drug Saf 2017; 17:207-216. [PMID: 29065722 DOI: 10.1080/14740338.2018.1397129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- William J Elliott
- a Department of Biomedical Sciences , Pacific Northwest University of Health Sciences , Yakima , WA , USA
| | - Evgeny A Bistrika
- a Department of Biomedical Sciences , Pacific Northwest University of Health Sciences , Yakima , WA , USA.,b Department of Medicine , Department of Veterans Affairs Medical Center , Boise , ID , USA
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Skibitsky VV, Fendrikova AV, Skibitsky AV. [Efficiency of triple antihypertensive therapy in patients with uncontrolled hypertension and depressive disorders]. TERAPEVT ARKH 2017; 89:22-28. [PMID: 28914847 DOI: 10.17116/terarkh201789822-28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the efficiency of triple antihypertensive therapy in patients with uncontrolled hypertension and depressive disorders (DD). MATERIAL AND METHODS 153 patients with uncontrolled hypertension were examined, of whom 82 patients were diagnosed with mild and moderate DD. A combination of perindopril 10 mg/day, indapamide SR 1.5 mg/day, and amlodipine at an initial dose of 5 mg/day was given to patients with hypertension and DD. After 4 weeks of treatment, if target blood pressure (BP) levels could not be achieved, the dose of amlodipine was increased up to 10 mg/day. General clinical examination and 24-hour BP monitoring (BPM) were performed in all the patients at baseline and in the patients with DD also after 24 weeks of therapy. The traditional measures of the diurnal BP profile, as well as the parameters characterizing arterial stiffness and central aortic pressure (CAP) were estimated. RESULTS After 8 weeks of therapy, target BP levels were recorded in 63 (76.8%) patients. After 24 weeks of treatment, the hypertensive patients with DD showed significant positive changes in all the investigated 24-hour BPM parameters and normalization of the diurnal BP profile in 65.1% of cases. During the treatment, there were significant decreases in pulse wave velocity, brachial arterial and aortic augmentation indices, aortic systolic and diastolic pressures, and mean aortic BP and an increase in the velocity of the reflected wave. CONCLUSION Triple therapy, including perindopril, indapamide SR, and amlodipine, contributed to the achievement of target BP levels in the majority of hypertensive patients with DD, with significant positive changes in all 24-hour BPM parameters, optimization of the diurnal BP profile in most patients, clinically significant improvement of the parameters that characterize arterial stiffness and CAP.
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Affiliation(s)
- V V Skibitsky
- Kuban State Medical University, Ministry of Health of Russia, Krasnodar, Russia
| | - A V Fendrikova
- Kuban State Medical University, Ministry of Health of Russia, Krasnodar, Russia
| | - A V Skibitsky
- Kuban State Medical University, Ministry of Health of Russia, Krasnodar, Russia
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