Improving blood pressure control and clinical outcomes through initial use of combination therapy in stage 2 hypertension

Real-life effectiveness, safety, and tolerability of amlodipine/valsartan or amlodipine/valsartan/hydrochlorothiazide single-pill combination in patients with hypertension from Pakistan

Objective:

EXCITE (clinical EXperienCe of amlodIpine and valsarTan in hypErtension) evaluated the real-life effectiveness, safety, and tolerability of single-pill combinations (SPCs) of amlodipine/valsartan (Aml/Val) and amlodipine/valsartan/hydrochlorothiazide (Aml/Val/HCTZ) in patients with hypertension from 13 countries in the Middle East and Asia. Here, we present data from Pakistan.

Methods:

This was a 26-week observational, multicenter, prospective, open-label study. At week 26, change from baseline in mean sitting systolic (msSBP) and diastolic blood pressure (msDBP) and the proportion of patients achieving BP goal (SBP/DBP <140/90 mmHg; <130/80 mmHg in patients with diabetes) and response rates (SBP <140 mmHg [130 mmHg for patients with diabetes] or reduction of ≥20 mmHg; DBP <90 mmHg [80 mmHg for patients with diabetes] or reduction of ≥10 mmHg), were evaluated. Incidence of adverse events (AEs) and serious AEs (SAEs) was recorded as safety variables. Subjective assessment of effectiveness, compliance and tolerability was done by the physician.

Results:

A total of 500 patients with hypertension (mean age of 48 years) were prescribed Aml/Val ( n = 471, 94%) or Aml/Val/HCTZ ( n = 29, 6%); 439 (87.8%) patients completed the study. At week 26, the mean BP decreased from 153.4/91.1 mmHg at baseline to 128.9/78.4 mmHg in the Aml/Val cohort (−24.5/−12.7 mmHg; p < 0.0001) and from 171.6/99.3 mmHg at baseline to 127.7/77.4 mmHg (−43.9/−21.9 mmHg; p < 0.0001) in the Aml/Val/HCTZ cohort. BP goals were achieved by 57% and 55.2% of patients in the Aml/Val and Aml/Val/HCTZ cohorts, respectively. A total of 40 (8%) patients reported at least one AE during the study period. Most common AEs included nausea (1.6%), headache (1.2%), vomiting (1.2%), and edema (1.2%). Most patients in Aml/Val cohort and all patients in Aml/Val/HCTZ cohort rated the effectiveness, compliance and tolerability as ‘good’ or ‘very good’.

Conclusions:

Aml/Val with or without HCTZ in a SPC was effective and well-tolerated for BP reduction in this cohort of patients with hypertension from Pakistan.

Are fixed-dose combination antihypertensives suitable as first-line therapy?

OBJECTIVE

To contemplate how initial antihypertensive therapy with fixed-dose combinations (FDC) might be incorporated into clinical practice, based on a compilation of evidence comparing FDCs with monotherapy and loose-dose combinations in varying patient populations.

METHODS

A non-systematic search of PubMed (from 2007 to 2012) was performed for randomized, controlled trials in order to capture the evidence on FDC versus monotherapy and loose-dose combinations as first-line therapy. The literature search focused on calcium channel blocker (CCB)-renin angiotensin system (RAS) blocker combinations. Additionally, any relevant papers known to the authors were included. International recommendations from published hypertension treatment guidelines were also consulted.

RESULTS

The results of this literature review identified two emergent issues. Firstly, there is a discord between antihypertensive use and actual blood pressure (BP) control achieved - despite an increase in the use of antihypertensives over the last 10 years, BP control rates remain low. Secondly, a greater association between BP and cardiovascular risk in Asians may magnify this discrepancy. A number of international guidelines are recommending early combination therapy, such as CCB-RAS blocker combinations in the majority of patients based on the available evidence, with such combinations showing benefits in terms of compliance, BP lowering and control, and safety. Additionally, recent studies have indicated that improved BP control may be achieved with simplified guidelines and the use of FDCs. Overall, these findings indicate that FDC could be used as first-line.

CONCLUSIONS

The findings from this literature review suggest that physicians may need to readdress their approach to antihypertensive treatment. Earlier use of antihypertensive FDC (including first-line) may help to shrink the current gap between antihypertensive use and BP target control achieved. Most guidelines acknowledge that combination therapy is required in the majority of patients, and FDC are regarded as a suitable alternative, having demonstrated better compliance compared with loose-dose combinations.

A Comparative Study of the Management of Stage 2 hypertension by Combined therapy with Losartan, Amlodipine and Hydrochlorothiazide

BACKGROUND

The most effective and accurate treatment of hypertensive patients reduces cardiovascular events and improves the quality of life.

OBJECTIVE

This study compared the efficacy and safety of combined (combination therapy) with an angiotensin-receptor blocker (ARB) a calcium-channel blocker (CCB) (Losartan / Amloidipine 50/10mg) vs maximal combination doses of ARB with hydrochlorothiazide (Losartan /HCTZ 100/25 mg) and maximal combination doses of CCB with HCTZ (Amlodipine /HCTZ 10/25 mg) in the management of stage 2 hypertension.

METHODS

This randomized clinical trial (RTC) comprised 478 hypertensive patients with mean age 50.5±5.21 years, and took place between January 2010 and December 2011 in Vasei Hospital clinic in Sabzevar. Antihypertensive drugs were washed out after 5 days of discontinuation of drugs and the patients with mean blood pressure in sitting position ≥ 160 and <200 mmHg in systole and ≥ 100 and <110 mmHg in diastole were randomized into three groups: Losartan / Amlodipine 50/10 mg (n =164) , Losartan / HCTZ 100/25 mg (n =155) and Amlodipine / HCTZ 10/25 mg (n =159). The end point was reaching the blood pressure below 140/90 within 56 days of treatment in each group.

RESULTS

There was a significant difference in systolic blood pressure reductions between treatment groups (P<0.001) and also there was a significant difference between groups in reducing diastolic blood pressure (P<0.01). The highest systolic and diastolic blood pressure reduction respectively was found in Amlodipine/losartane and losartane/HTCZ group. The ANCOVA analysis revealed that only treatment regimen had a significant effect (P=0.01) and other factor including Age, Gender, Diabetes Mellitus, Smoking and High serum cholesterol didn't have significant effect on blood pressure reduction.

CONCLUSION

ARB/CCB combination therapy reduced blood pressure more effectively than the maximal doses of ARB or CCB with HCTZ in stage 2 hypertensive patients within this period of study.

Ambulatory blood pressure response to triple therapy with an angiotensin-receptor blocker (ARB), calcium-channel blocker (CCB), and HCTZ versus dual therapy with an ARB and HCTZ

BACKGROUND

Stage 2 hypertension often requires combination antihypertensive therapy. Ambulatory blood pressure monitoring (ABPM) is a useful tool for assessing antihypertensive drugs and their combinations.

OBJECTIVE

To compare the effect of a moderate dose of angiotensin receptor blocker/calcium channel blocker (ARB/CCB) combined with a diuretic versus a maximal dose of ARB with a diuretic on 24-hour ambulatory blood pressure monitoring (ABPM) and other derived ambulatory blood pressure (ABP) parameters.

METHODS

The EXforge As compared to Losartan Treatment ABPM substudy was a randomized, double-blind, parallel-group, active-control, forced-titration study of patients with Stage 2 hypertension that compared the efficacy of initial treatment with valsartan/amlodipine 160/5 mg (n = 48) or losartan 100 mg (n = 36). At week 3, hydrochlorothiazide (HCTZ) 25 mg was added in both treatment groups. ABP was measured at baseline and at week 6. Additionaly, 24-hour ABP, nighttime (10 pm to 6 am) and daytime (6 am to 10 pm) ABP, and ABP load (percentage of readings above 140/90 mmHg) were determined.

RESULTS

Eighty-four patients (48 ARB/CCB/HCTZ, 36 ARB/HCTZ) had ABPM at baseline and at week 6. Reductions of systolic/diastolic ABP were greater in the ARB/CCB/ HCTZ group than in the ARB/HCTZ group for 24-hour mean ABP (-22.0/-13.3 versus -17.4/-8.1 mmHg), as well as nighttime ABP (-22.2/-13.3 versus -16.2/-7.4 mmHg), daytime ABP (-21.9/-13.0 versus -18.1/-8.6 mmHg), ABP in the last 4 hours of the dosing period (-21.5/-13.5 versus -17.0/-7.7 mmHg), and ABP load (21.7%/12.8% versus 30.8%/20.0%).

CONCLUSION

Initiating antihypertensive treatment with moderate doses of ARB/CCB with a diuretic is more effective in lowering nighttime and daytime ABP and reducing ABP load than a maximal dose of an ARB with a diuretic.

Evaluation of pharmacokinetic interactions between amlodipine, valsartan, and hydrochlorothiazide in patients with hypertension

The steady-state pharmacokinetic (PK) interaction potential between amlodipine (10 mg), valsartan (320 mg), and hydrochlorothiazide (HCTZ; 25 mg) was evaluated in patients with hypertension in a multicenter, multiple-dose, open-label, 4-cohort, parallel-group study. Eligible patients were randomly allocated to the dual combination of valsartan + HCTZ, amlodipine + valsartan, or amlodipine + HCTZ and nonrandomly allotted to amlodipine + valsartan + HCTZ triple combination treatment. After 6 days of treatment with a half-maximal dose of different combinations, patients were up-titrated to the maximal drug doses from day 7 through day 17. PK parameters of corresponding analytes from the triple- and dual-treatment groups were estimated on day 17 and compared. Safety and tolerability of all treatments was assessed. The C ( ssmax ) and AUC(0-τ) values of amlodipine or HCTZ remained unaffected when administered with valsartan + HCTZ or valsartan + amlodipine, respectively. On the other hand, valsartan exposure increased by 10% to 25% when coadministered with HCTZ and amlodipine, which is not considered clinically relevant. In conclusion, there were no clinically relevant PK interactions with amlodipine, valsartan, and HCTZ triple combination compared with the corresponding dual combinations. All treatments were safe and well tolerated.

Is there a nonadherent subtype of hypertensive patient? A latent class analysis approach

To determine subtypes of adherence, 636 hypertensive patients (48% White, 34% male) reported adherence to medications, diet, exercise, smoking, and home blood pressure monitoring. A latent class analysis approach was used to identify subgroups that adhere to these five self-management behaviors. Fit statistics suggested two latent classes. The first class (labeled "more adherent") included patients with greater probability of adhering to recommendations compared with the second class (labeled "less adherent") with regard to nonsmoking (97.7% versus 76.3%), medications (75.5% versus 49.5%), diet (70.7% versus 46.9%), exercise (63.4% versus 27.2%), and blood pressure monitoring (32% versus 3.4%). Logistic regression analyses used to characterize the two classes showed that "more adherent" participants were more likely to report full-time employment, adequate income, and better emotional and physical well-being. Results suggest the presence of a less adherent subtype of hypertensive patients. Behavioral interventions designed to improve adherence might best target these at-risk patients for greater treatment efficiency.

Effectiveness of initiating treatment with valsartan/hydrochlorothiazide in patients with stage-1 or stage-2 hypertension

This prospective, 6-week, multicenter, double-blind study examined the benefits of initiating treatment with combination valsartan/hydrochlorothiazide (HCTZ) compared with initial valsartan monotherapy for 648 patients with stage-1 or stage-2 hypertension (age=52.6±10 years; 54% male; baseline blood pressure (BP)=161/98 mm Hg, 32% stage 1). Patients were randomized to valsartan 80 mg (V-low), valsartan 160 mg (V-high) or valsartan/HCTZ 160/12.5 mg (V/HCTZ), and electively titrated after weeks 2 and 4 to the next dosage level (maximum dose valsartan/HCTZ 160/25 mg) if BP remained >140/90 mm Hg. At end of the study, patients initiated with V/HCTZ required less titration steps compared with the initial valsartan monotherapy groups (63 vs 86% required titration by study end, respectively) and reached the target BP goal of <140/90 mm Hg in a shorter period of time (2.8 weeks) (P<0.0001) vs V-low (4.3 weeks) and V-high (3.9 weeks). Initial combination therapy was also associated with higher BP control rates and greater reductions in both systolic and diastolic BP from baseline (63%, −27.7±13/–15.1±8 mm Hg) compared with V-low (46%, −21.2±13/−11.4±8 mm Hg, P<0.0001) or V-high (51%, −24.0±13/−12.0±10 mm Hg, P<0.01). Overall and drug-related AEs were mild to moderate and were similar between V/HCTZ (53.1 and 14.1%, respectively) and the two monotherapy groups, V-low (50.5 and 13.8%) and V-high (50.7 and 11.8%). In conclusion, initiating therapy with a combination of valsartan and low-dose HCTZ results in early, improved BP efficacy with similar tolerability as compared with starting treatment with a low or higher dose of valsartan for patients with stage-1 and stage-2 hypertension.

Complementary mechanisms of angiotensin receptor blockers and calcium channel blockers in managing hypertension

Hypertension affects approximately 73 million individuals in the United States. Clinical studies have shown that antihypertensive therapy can reduce blood pressure (BP) and the risk of cardiovascular events. However, the majority of patients with hypertension do not achieve the recommended BP goal of < 140/90 mm Hg (or < 130/80 mm Hg for patients with diabetes) with antihypertensive monotherapy, and require therapy with 2 or more antihypertensive agents. Combination therapy utilizes antihypertensive agents from different drug classes, which act via distinct pharmacologic mechanisms to improve overall efficacy and tolerability. Although combination therapy is superior to monotherapy in achieving BP goals across the entire spectrum of hypertension, the proportion of patients achieving the recommended BP goal can be further improved by the use of new antihypertensive drug combinations. The beneficial antihypertensive characteristics of both angiotensin receptor blockers and calcium channel blockers suggest that combining these classes may result in a highly efficacious antihypertensive therapy with regard to both activity and safety when used as a fixed-dose combination. In particular, a fixed-dose combination of olmesartan medoxomil plus amlodipine besylate has been demonstrated to be an efficacious antihypertensive combination due in part to the benefits associated with each of these agents within their respective drug classes.

The association of emotional well-being and marital status with treatment adherence among patients with hypertension

We were interested in examining the relationship between psychosocial factors and hypertension-related behaviors. We hypothesized that lower emotional well-being and unmarried status would be related to higher BP, poorer medication adherence, greater difficulty adhering to diet and exercise, and current smoking. In a cross-sectional design, 636 hypertensive patients completed the Mental Component Summary (MCS) Scale of the SF-12 and rated their difficulty with adherence to diet, exercise, and medication-taking. In logistic regression analyses, lower MCS scores were associated with difficulty adhering to diet (OR = 0.97, p < .05) and exercise (OR = 0.97, p < .01), and current smoking status (OR = 0.98, p < .05). Being married was associated with higher probability of medication adherence (OR = 1.66, p < .01) and a lower probability of being a current smoker (OR = 0.34, p < .0001). Neither MCS scores nor being married were related to BP levels in adjusted analyses. Results emphasize the importance of assessing psychosocial factors to optimize hypertension treatment.

Assessment of adherence, persistence, and costs among valsartan and hydrochlorothiazide retrospective cohorts in free-and fixed-dose combinations

OBJECTIVES

To assess medication adherence, persistence, and costs between cohorts of patients in managed care settings using a fixed-dose combination (FDC) or individual components (IC) of valsartan and hydrochlorothiazide in an insurance claims database.

METHODS

Medical and prescription claims for hypertensive patients using a combination of valsartan and HCTZ were identified from the IHCIS National Managed Care Benchmark Database via a retrospective cohort analysis. Study subjects had at least 110 days prior to start of study medications during which no other antihypertensive medications were prescribed, and were followed for 12 months. Claims for 8711 adult patients were analyzed for adherence, persistence and costs. General linear regression was conducted to detect differences in adherence among groups. Covariates included age, gender, persistence, number on concomitant cardiovascular drugs, and number of cardiovascular diagnoses.

RESULTS

Most subjects used an FDC product (N=8150, 93.6%) vs. the IC (N=561, 6.4%). The FDC group had a larger portion of males and less concomitant cardiovascular medications or disease. A random sample of 1628 of the FDC subjects had improved values for medication adherence compared to the IC group (62.1 vs. 53.0%, p<0.001) and persistence values were improved at both 180 days (73 vs. 28%, p<0.001) and 365 days (54 vs. 19%, p<0.001). Both prescription drug costs ($1587 vs. $2050, p<0.001) and medical costs ($3343 vs. $3817, p<0.001) were lower in the FDC cohorts.

CONCLUSIONS

The use of fixed-dose therapy in hypertension may lead to increased adherence and persistence with a positive financial impact on both prescription and total medical costs. As with any retrospective claims database analysis, unobserved systematic differences between the two medication groups may exist.