The Effects of an Olmesartan Medoxomil-Based Treatment Algorithm on 24-Hour Blood Pressure Levels in Elderly Patients Aged 65 and Older

Angiotensin Receptor Blockers in the Management of Hypertension: A Real-World Perspective and Current Recommendations

Hypertension represents a major common cardiovascular risk factor. Optimal control of high blood pressure levels is recommended to reduce the global burden of hypertensive-mediated organ damage and cardiovascular (CV) events. Among the first-line drugs recommended in international guidelines, renin-angiotensin-aldosterone system antagonists [angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs)] have long represented a rational, effective, and safe anti-hypertensive pharmacological strategy. In fact, current US and European guidelines recommend ACEi and ARBs as a suitable first choice for hypertension treatment together with calcium channel blockers (CCBs) and thiazide diuretics. Different studies have demonstrated that ARBs and ACEi exert a comparable effect in lowering blood pressure levels. However, ARBs are characterized by better pharmacological tolerability. Most importantly, the clinical evidence supports a relevant protective role of ARBs toward the CV and renal damage development, as well as the occurrence of major adverse CV events, in hypertensive patients. Moreover, a neutral metabolic effect has been reported upon ARBs administration, in contrast to other antihypertensive agents, such as beta-blockers and diuretics. These properties highlight the use of ARBs as an excellent pharmacological strategy to manage hypertension and its dangerous consequences. The present review article summarizes the available evidence regarding the beneficial effects and current recommendations of ARBs in hypertension. The specific properties performed by these agents in various clinical subsets are discussed, also including an overview of their implications for the current COVID-19 pandemic.

ARB-Based Combination Therapy for the Clinical Management of Hypertension and Hypertension-Related Comorbidities: A Spotlight on Their Use in COVID-19 Patients

Essential hypertension is the most common cardiovascular (CV) risk factor, being primarily involved in the pathogenesis of CV disease and mortality worldwide. Given the high prevalence and growing incidence of this clinical condition in the general population in both high and low-income countries, antihypertensive drug therapies are frequently prescribed in different hypertension-related CV diseases and comorbidities. Among these conditions, evidence are available demonstrating the clinical benefits of lowering blood pressure (BP) levels, particularly in those hypertensive patients at high or very high CV risk profile. Preliminary studies, performed during the Sars-COVID-19 epidemic, raised some concerns on the potential implication of hypertension and antihypertensive medications in the susceptibility of having severe pneumonia, particularly with regard to the use of drugs inhibiting the renin-angiotensin system (RAS), including angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs). These hypotheses were not confirmed by subsequent studies, which independently and systematically demonstrated no clinical harm of these drugs also in patients with Sars-COVID-19 infection. The aim of this narrative review is to critically discuss the available evidence supporting the use of antihypertensive therapies based RAS blocking agents in hypertensive patients with different CV risk profile and with additional clinical conditions or comorbidities, including Sars-COVID-19 infection, with a particular focus on single-pill combination therapies based on olmesartan medoxomil.

Renin-Angiotensin System Blockers and Statins Are Associated With Lower In-Hospital Mortality in Very Elderly Hypertensives

OBJECTIVES

Cardiovascular diseases are mainly related to hypertension and dyslipidemia and increase with aging because of the larger time span for these risk factors to damage arterial blood vessels. The impact of cardiovascular drug therapy on outcomes in the very elderly hospitalized is still not well established. The aim of our study was to evaluate the associations between cardiovascular therapy and in-hospital mortality in very elderly hypertensives.

DESIGN

Prospective observational study.

SETTING

Hospital assessment.

PARTICIPANTS

310 very elderly hypertensive patients admitted to our Internal Medicine and Geriatrics Department for medical conditions.

MEASUREMENTS

Main comorbidities, laboratory parameters, and cardiovascular drug therapy taken before admission were considered for the analyses.

RESULTS

The mean age was 88.1 ± 5.1 years, with female prevalence of 57.4%. Among cardiovascular drugs taken before admission, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers and statins were those associated with lower in-hospital mortality, even after adjusting for covariates (age, hemoglobin, albumin, acute kidney injury, ADL Hierarchy Scale, NT-proBNP levels) [odds ratio (OR) = 0.46, P = .045, and OR = 0.21, P = .008, respectively]. No difference regarding in-hospital mortality was found between ACE inhibitors and angiotensin receptor blockers (P = .414).

CONCLUSION

ACE inhibitors/angiotensin receptor blockers and statins, through their beneficial effects on the cardiovascular system, have a positive impact on survival in very elderly hospitalized patients. Our data confirm the important role of such drugs even in this particular population with a mean age higher than 88 years, where scientific evidence is still scanty.

Monotherapy and Dual Combination Therapies Based on Olmesartan: A Comprehensive Strategy to Improve Blood Pressure Control

Olmesartan medoxomil is an antihypertensive drug of the class of angiotensin II type 1 (AT1) receptor antagonists (or blockers), characterized by tight and prolonged binding to AT1 receptor compared to other molecules within the same class. These characteristics produce effective and sustained blood pressure reductions in hypertensive patients at different cardiovascular risk profile with a good tolerability profile. After a brief description of the pharmacological characteristics of olmesartan, we will provide a thorough overview of the clinical studies that investigated its efficacy and safety in the clinical management of hypertensive patients both in monotherapy and in dual combination therapies with either thiazide diuretics or calcium channel blockers. These studies demonstrated that olmesartan-based antihypertensive strategy may indeed provide sustained BP control over the 24-h period in a wide proportion of hypertensive patients, thus contributing to a substantial progress in hypertension management. Finally, since growing evidence suggest that olmesartan may also exert potential favourable effects at vascular level, thereby antagonizing the vascular inflammatory process involved in the development and progression of atherosclerosis, the main clinical studies addressing this issue will be also discussed.

Olmesartan vs ramipril in the treatment of hypertension and associated clinical conditions in the elderly: a reanalysis of two large double-blind, randomized studies at the light of the most recent blood pressure targets recommended by guidelines

In this paper, we present the results of a reanalysis of the data of two large randomized, double-blind, parallel group studies with a similar design, comparing the efficacy of an angiotensin-receptor blocker (olmesartan medoxomil) with that of an angiotensin-converting enzyme inhibitor (ramipril), by applying two different blood pressure targets recently recommended by hypertension guidelines for all patients, irrespective of the presence of diabetes (<140/90 mmHg), and for elderly hypertensive patients (<150/90 mmHg). The efficacy of olmesartan was not negatively affected by age, sex, hypertension type, diabetes status or other concomitant clinical conditions, or cardiovascular risk factors. In most cases, olmesartan provided better blood pressure control than ramipril. Olmesartan was significantly more effective than ramipril in male patients, in younger patients (aged 65-69 years), in those with metabolic syndrome, obesity, dyslipidemia, preserved renal function, diastolic ± systolic hypertension, and, in general, in patients with a high or very high cardiovascular risk. Interestingly, patients previously untreated or treated with two or more antihypertensive drugs showed a significantly larger response with olmesartan than with ramipril. Thus, our results confirm the good efficacy of olmesartan in elderly hypertensives even when new blood pressure targets for antihypertensive treatment are considered. Such results may be relevant for the clinical practice, providing some hint on the possible different response of elderly hypertensive patients to two different drugs acting on the renin-angiotensin system, when patients are targeted according to the blood pressure levels recommended by recent hypertension guidelines.

Olmesartan in the treatment of hypertension in elderly patients: a review of the primary evidence

Hypertension, particularly systolic hypertension, is prevalent in the elderly and increases with advancing age, in part because of age-related endothelial dysfunction and increased arterial stiffness. There is strong evidence from randomized clinical trials that supports the use of antihypertensive treatment for effective and sustained blood pressure (BP) control in older patients to reduce the risk of vascular-related morbidity and mortality, particularly cerebrovascular accidents, including stroke. Furthermore, current evidence and guidelines suggest that all major classes of antihypertensive agents are equally effective in controlling BP and preventing cardiovascular events in older patients. Diuretics are commonly used in elderly patients, but recent outcomes data have raised doubt about their long-term benefits. Renin-angiotensin system inhibitors have a better tolerability profile than diuretics. Extensive clinical evidence has demonstrated the excellent efficacy and tolerability profile of olmesartan medoxomil (OM)--an angiotensin II receptor blocker AT1 receptor antagonist--including in elderly patients. Randomized and observational studies have shown that OM provides effective BP control across the 24 h dosing interval in the elderly. It also has a good tolerability profile, a pharmacokinetic profile unaffected by age and a low propensity for drug interactions. An additional factor is that OM once-daily regimens are simple and straightforward, which can be an important factor in maintaining adherence to therapy in elderly patients. This article provides an overview of the main recent clinical evidence supporting the use of OM-based therapy in elderly patients with hypertension.

Safety, tolerability, and efficacy of a fixed-dose combination of olmesartan 40 mg and hydrochlorothiazide 12.5/25 mg in daily practice

BACKGROUND

The safety and efficacy of olmesartan 40 mg and hydrochlorothiazide (HCTZ) as a fixed-dose combination has been investigated in clinical trials leading to its approval. The aims of the present study were to confirm these data in an unselected patient population in daily practice and to determine the impact of physical activity on blood pressure control.

METHODS

In a multicenter, noninterventional study, 3,333 patients with either insufficient blood pressure control on olmesartan 40 mg alone or on a fixed/free combination of olmesartan 40 mg and HCTZ 12.5/25 mg were primarily assessed for safety and tolerability of the fixed-dose combination of olmesartan 40 mg and HCTZ 12.5/25 mg at 24 ± 2 weeks. Secondary objectives were blood pressure reduction, treatment compliance, and impact of physical activity as measured by the sum of weekly energy costs.

RESULTS

The mean patient age was 63.2 ± 11.46 years, mean baseline blood pressure was 159.6 ± 15.28/93.5 ± 9.52 mmHg, and 70.9% had at least one additional cardiovascular risk factor. Adverse drug reactions were rare (n = 19), and no serious adverse drug reactions occurred. Compliance with drug therapy was at least sufficient in more than 99% of patients at the end of the study. Blood pressure at the last available visit was reduced by 26.1 ± 15.5/13.0 ± 10.1 mmHg versus baseline (P < 0.0001), but had reduced effectiveness in patients ≥75 years with diabetes or impaired renal function. In 69% of patients, blood pressure was normalized (<140/90 mmHg). No noteworthy differences in baseline characteristics or baseline blood pressure were found between patients with an activity level (sum of weekly energy costs) above or below the median of 9,460.6. A higher versus lower physical activity score had no impact on blood pressure reduction.

CONCLUSION

Our data confirm randomized trial data concerning safe and efficient blood pressure reduction using a fixed-dose combination of olmesartan 40 mg and HCTZ 12.5/25 mg in a large, unselected patient population, independent of physical activity level.

Combined olmesartan, amlodipine, and hydrochlorothiazide therapy in randomized patients with hypertension: a subgroup analysis of the TRINITY study by age

Background

Hypertension is often inadequately controlled in older people.

Objective

This prespecified subgroup analysis assessed the efficacy and safety of an olmesartan medoxomil (OM) 40 mg/amlodipine besylate (AML) 10 mg/hydrochlorothiazide (HCTZ) 25 mg triple-combination treatment compared with the 3 components as dual-combination treatments in participants with hypertension who were <65 and ≥65 years of age. Within the ≥65 years of age subgroup, efficacy and safety were also summarized for participants ≥75 years of age.

Study design

12-week, multicenter, double-blind, randomized, parallel-group study.

Setting

317 ambulatory care sites in the US and Puerto Rico.

Participants

Individuals ≥18 years of age with mean seated blood pressure (SeBP) ≥140/100 or ≥160/90 mmHg off antihypertensive medication on 2 consecutive clinic visits with no recent history of significant cerebrovascular disease, coronary artery disease, heart failure (New York Heart Association class III or IV), severe renal insufficiency, or uncontrolled diabetes (HbA_1c >9 %).

Intervention

Participants were randomized, stratified by age, diabetes status, and race to one of four treatment assignments: OM 40/AML 10/HCTZ 25 mg, OM 40/AML 10 mg, OM 40/HCTZ 25 mg, or AML 10/HCTZ 25 mg.

Main Outcome Measure

Least squares (LS) mean change from baseline in seated diastolic blood pressure (SeDBP) at week 12 (last observation carried forward) in each age subgroup (prespecified analysis).

Results

Of the 2492 randomized participants in the study (total cohort), 2021 (81.1 %) were <65 and 471 (18.9 %) were ≥65 years of age, including 79 (3.2 %) who were ≥75 years of age. OM 40/AML 10/HCTZ 25 mg triple-combination treatment resulted in a significantly greater reduction in LS mean SeDBP at week 12 than dual-combination component treatments in participants in both cohorts: <65 years (21.0 vs. 14.2–17.2 mmHg; p < 0.0001) and ≥65 years (23.7 vs. 17.3–20.0 mmHg; p ≤ 0.002). Similarly, triple-combination treatment resulted in a greater reduction in LS mean seated systolic blood pressure (SeSBP) at week 12 than dual-combination component treatments: <65 years (38.2 vs. 28.3–31.4 mmHg; p < 0.0001) and ≥65 years (39.2 vs. 29.3–31.1 mmHg; p < 0.0001). Triple-combination treatment was more effective than dual-combination treatments in enabling participants to reach SeBP goal (<140/90 mmHg [<130/80 mmHg in participants with diabetes, chronic kidney disease, or chronic cardiovascular disease]) in both age subgroups (<65 years: 65 vs. 34–50 %, respectively, p < 0.0001 and ≥65 years: 63 vs. 32–39 %; p ≤ 0.0004). All 4 treatments were safe and well tolerated with low discontinuation rates in both age subgroups. There were no clinically relevant differences in the incidence of treatment-emergent adverse events between participants <65 and ≥65 years of age receiving triple-combination treatment.

Conclusion

Triple-combination treatment with OM 40/AML 10/HCTZ 25 mg was well tolerated and more effective in lowering BP than the component dual-combination treatments in elderly and non-elderly subgroups.

Olmesartan medoxomil-based antihypertensive therapy evaluated by ambulatory blood pressure monitoring: efficacy in high-risk patient subgroups

Hypertension affects approximately 26% of the world's adult population and is a recognized major risk factor for morbidity and mortality associated with cardiovascular, cerebrovascular, and renal diseases. However, despite the availability of a range of effective antihypertensive agents and a growing awareness of the consequences of high blood pressure (BP), the treatment and control of hypertension remains suboptimal. A number of patient subgroups are categorized as 'high risk' and may have hypertension that is more difficult to treat, including obese individuals, patients with stage 2 hypertension, those with type 2 diabetes mellitus (T2DM), patients with coronary artery disease or a history of stroke, and Black patients. As the benefits of lowering BP in patients with hypertension are unequivocal, particularly in high-risk patients, treating high-risk patients with hypertension to BP goals and maintaining 24-hour BP control is important to help reduce cardiovascular risk and improve outcomes. Although the BP goals recommended in current consensus guidelines for the management of patients with hypertension are based on cuff BP measurements, ambulatory BP monitoring (ABPM) provides a valuable diagnostic tool and allows a more accurate assessment of BP levels throughout the 24-hour dosing period. ABPM is a better predictor of prognosis than office BP measurement and is also useful for assessing whether antihypertensive therapy remains effective in the critical last few hours of the dosing period, which usually coincides with the morning BP surge associated with arousal and arising. ABPM has been adopted by new evidence-based guidelines in the United Kingdom to confirm a suspected diagnosis of hypertension, which is an indication of the growing importance of ABPM in the management of hypertension. This review provides an overview of the efficacy and safety of antihypertensive therapy based on olmesartan medoxomil ± hydrochlorothiazide and amlodipine/olmesartan medoxomil in high-risk patient populations enrolled in studies that reported ambulatory BP endpoints. The studies identified in this review showed that a titrate-to-BP goal strategy using olmesartan medoxomil- or amlodipine/olmesartan medoxomil-based antihypertensive therapy was an effective and well-tolerated approach for maintaining BP control throughout the full 24-hour dosing period in high-risk patients with difficult-to-treat hypertension.

How do compliance, convenience, and tolerability affect blood pressure goal rates?

Uncontrolled hypertension imposes a substantial global health burden, and poor patient compliance with prescribed antihypertensive medication makes a major contribution to the development of suboptimal blood pressure (BP) control. The asymptomatic nature of hypertension, side effects of medication, treatment complexity, and high pill burdens all have a negative impact on patient compliance. It is important to address the issue of poor patient compliance as studies have shown that good compliance is associated with improvement of BP control and positive health outcomes. As the majority of hypertensive patients require treatment with two or more agents to achieve goal BP, treatment guidelines have acknowledged the value of simplifying treatment through the use of fixed-dose combination (FDC) therapy. Triple FDC therapy comprising an angiotensin II type 1 receptor antagonist (angiotensin receptor blocker), calcium channel blocker, and thiazide diuretic is a novel treatment strategy for the improvement of BP control in hard-to-treat patients.

Efficacy of olmesartan medoxomil and hydrochlorothiazide fixed-dose combination therapy in patients aged 65 years and older with stage 1 and 2 hypertension or isolated systolic hypertension

BACKGROUND

The incidence of hypertension, particularly isolated systolic hypertension, increases with increasing age, as does the risk of fatal cardiovascular disease. A combination antihypertensive therapy regimen may be required to reach recommended BP goals in older patients.

OBJECTIVES

This study set out to report blood pressure (BP) data in elderly patients across the subgroups of stage 1 and stage 2 hypertension (prespecified subgroup) and isolated systolic hypertension (ISH) [post hoc].

DESIGN AND SETTING

This was a subgroup analysis of a prospective, open-label study carried out in a multicenter, outpatient setting (e.g. the BeniSILVER [Benicar Efficacy: New Investigation Shows OM Treatment Increasingly Leads to Various Elderly Populations to Safe BP Reductions; ClinicalTrials.gov identifier: NCT00412932] study). The study included 176 patients with a mean age of approximately 72 years; stage 1 hypertension, 60, stage 2 hypertension, 116, and ISH, 98.

INTERVENTION

After a 2- to 3-week placebo run-in period, patients were uptitrated every 3 weeks from olmesartan medoxomil (OM) 20 mg daily to OM 40 mg, OM/hydrochlorothiazide (HCTZ) 40 mg/12.5 mg, and OM/HCTZ 40 mg/25 mg, if seated cuff BP (SeBP) was ≥120/70 mmHg.

MEASUREMENTS

Measurements included change from baseline in mean 24-hour ambulatory BP and SeBP after 12 weeks of treatment, percentage of patients achieving a cumulative SeBP goal of <140/90 mmHg (stage 1 and stage 2 cohorts) or seated cuff systolic BP (SeSBP) goal of <140 mmHg (ISH cohort), and the incidence of adverse events (AEs).

RESULTS

Combination therapy was required by 159 patients. Changes from baseline in mean 24-hour ambulatory BP (± standard deviation [SD]) were -24.2 (± 11.8)/-11.8 (± 6.9) mmHg, -26.5 (± 11.8)/-12.6 (± 6.7) mmHg, and -24.7 (± 12.5)/-11.2 (± 6.4) mmHg in the stage 1, stage 2, and ISH cohorts, respectively (all p < 0.001 vs baseline). Mean SeBP changes (± SD) from baseline in patients titrated to OM/HCTZ 40 mg/25 mg were -24.6 (± 11.4)/-10.5 (± 7.3) mmHg in the stage 1 cohort, -26.4 (± 17.2)/-11.3 (± 9.7) mmHg in the stage 2 cohort, and -21.5 (± 15.6)/-6.8 (± 7.8) mmHg in the ISH cohort (all p < 0.001). The cumulative proportions of patients achieving an SeBP goal of <140/90 mmHg by week 12 were 88.3%, 56.0%, and 72.4% in the stage 1, stage 2, and ISH cohorts, respectively, while 72.4% of patients achieved an SeSBP of <140 mmHg in the ISH cohort. Treatment-emergent AEs ranged from 32.3% to 32.8%, with <3% of patients reporting drug-related hypotension.

CONCLUSION

An OM/HCTZ-based titration regimen enabled elderly patients with hypertension to safely reduce BP throughout the 24-hour dosing interval and allowed the majority of these patients to achieve a BP target of <140/90 mmHg or <140 mmHg.

Blood pressure-lowering efficacy of an olmesartan medoxomil/hydrochlorothiazide-based treatment algorithm in elderly patients (age ≥65 years) stratified by age, sex and race: subgroup analysis of a 12-week, open-label, single-arm, dose-titration study

INTRODUCTION

Hypertension is a leading risk factor for development of heart failure, stroke and renal disease in the elderly.

OBJECTIVE

The objective of this study was to evaluate, by means of a prespecified secondary analysis of a 12-week, open-label, single-arm, dose-titration study, the blood pressure (BP)-lowering efficacy and safety of an olmesartan medoxomil (OM)/hydrochlorothiazide (HCTZ)-based titration regimen in patients aged ≥65 years with hypertension. Subgroups were stratified by age (≥65 to ≤75 or >75 years), sex (male or female) and race (Black or non-Black).

METHODS

Following a 2- to 3-week placebo run-in phase, patients received OM 20 mg, uptitrated to OM 40 mg, followed by addition of HCTZ 12.5-25 mg step-wise at 3-week intervals if seated cuff BP (SeBP) was ≥120/70 mmHg. Patients below this target SeBP were maintained at their current dose but uptitrated to the next consecutive dose if mean seated cuff systolic BP (SBP) was ≥140 mmHg and/or mean seated cuff diastolic BP was ≥90 mmHg at follow-up visits. Efficacy was assessed by 24-hour ambulatory BP monitoring (ABPM) and SeBP measurements. The primary efficacy variable was the change from baseline in mean 24-hour ambulatory SBP after 12 weeks. Secondary efficacy endpoints included the change from baseline in mean 24-hour ambulatory SBP; change from baseline in ambulatory BP during the daytime (8:00 am-4:00 pm), nighttime (10:00 pm-6:00 am) and the last 6, 4 and 2 hours of the dosing interval; change from baseline in SeBP at each titration step and at study end; and the proportion of patients achieving mean 24-hour ambulatory BP targets and SeBP goals at week 12. The frequency and severity of treatment-emergent adverse events (TEAEs) were also documented.

RESULTS

Baseline and week 12 ABPM data were available for 150 out of 178patients who entered the active treatment phase. Changes from baseline in mean 24-hour ambulatory BP were -26.0/-12.5 mmHg and -24.9/-12.0 mmHg in patients aged ≥65 to ≤75 years (n = 128) and >75 years (n = 48), respectively (all p < 0.0001 vs baseline). Changes from baseline in mean 24-hour ambulatory BP were -26.0/-13.0 mmHg and -25.4/-11.5 mmHg in male (n = 92) and female (n = 84) patients, respectively (all p < 0.0001 vs baseline) and -26.7/-11.8 mmHg and -25.6/-12.4 mmHg in Black (n = 28) and non-Black (n = 148) patients, respectively (all p < 0.0001 vs baseline). Clinically significant ambulatory BP reductions were observed during the daytime, nighttime and the last 6, 4 and 2 hours of the dosing interval in all subgroups. Changes from baseline at week 12 in mean SeBP were similar to 24-hour ambulatory BP changes reported previously. At week 12, the proportion of patients achieving the 24-hour ambulatory BP target of <130/80 mmHg ranged from 67.5% to 77.4% and achieving the SeBP goal of <140/90 mmHg ranged from 60.7% to 68.8% across the subgroups. Most TEAEs and drug-related TEAEs were mild or moderate in severity, and there were no trends across subgroups.

CONCLUSIONS

In a subgroup analysis based upon age, sex and race in patients aged ≥65 years with hypertension, an OM/HCTZ-based algorithm was efficacious and well tolerated. ClinicalTrials.gov Identifier: NCT00412932.

Integrated control of hypertension by olmesartan medoxomil and hydrochlorothiazide and rationale for combination

Hypertension affects nearly one-third of all individuals in the US, yet one-half of all treated patients achieve blood pressure (BP) controlled to recommended goals. The percentage of patients with uncontrolled BP is likely to be much higher when considering the number of patients who are not even aware of their hypertensive state. Elevated BP is associated with increased risks of cardiovascular events and end-organ damage. Antihypertensive monotherapy is not always sufficient to achieve BP goals, and thus more aggressive treatment regimens need to be considered. Antihypertensive combination therapy, which may improve tolerability, offers the benefit of targeting different mechanisms of action. Numerous outcomes studies support the use of a renin–angiotensin system inhibitor as a first-line choice in antihypertensive therapy. This review discusses the benefits of combination therapy with the angiotensin type II receptor blocker olmesartan medoxomil (OM) paired with the thiazide diuretic hydrochlorothiazide (HCTZ). The pharmacokinetic properties of OM will be reviewed in addition to efficacy studies that support OM + HCTZ combination therapy over other possible antihypertensive combinations. Finally, a rationale for choosing HCTZ over another diuretic, chlorthalidone, will also be discussed based on pharmacokinetic differences, clinical concerns, and trends in use.

Angiotensin II receptor blocker combinations: from guidelines to clinical practice

European guidelines recommend a combination of at least two antihypertensive drugs to achieve blood pressure (BP) goals in the majority of patients. In addition, they encourage simplification of treatment regimens using single-pill, fixed-dose combinations (FDCs) to aid compliance. Of the preferred combinations, those based on angiotensin II receptor blockers (ARBs) may be more desirable than those based on angiotensin-converting enzyme inhibitors, because of equivalent efficacy and superior tolerability. Significantly better BP reductions and control rates have been observed with the dual combinations of ARBs with amlodipine or hydrochlorothiazide (HCZT) compared with component monotherapies. Furthermore, in the 15-20% of patients who require triple combination therapy to achieve BP goals, fixed-dose triple combinations with an ARB, calcium-channel blocker and diuretic, which have recently become available, provide significantly better BP reductions and control compared with dual combinations. Within the ARB class, olmesartan stands out as being one that has been recently investigated in a considerable number of studies that are relevant to the modern concept of FDC therapy in terms of both dual and triple combination therapy. The availability of such single-pill FDCs has the potential to deliver strong antihypertensive efficacy with good tolerability and improved compliance.

An olmesartan medoxomil-based treatment algorithm is effective in achieving 24-hour BP control in patients with type 2 diabetes mellitus, regardless of age, race, sex, or severity of hypertension: subgroup analysis of the BENIFICIARY study

BACKGROUND

Hypertension often occurs concomitantly with diabetes mellitus, such that >50% of adults with type 2 diabetes have hypertension. These individuals are at a greater risk of developing renal and cardiovascular disease. The currently recommended BP goal of <130/80 mmHg for patients with type 2 diabetes is achieved in only 37.5% of treated patients with diabetes and hypertension.

METHODS

The antihypertensive efficacy of olmesartan medoxomil (OM) ± hydrochlorothiazide (HCTZ) was investigated in prespecified subgroups (age <65/≥65 years, Blacks/non-Blacks, males/females, or stage 1/stage 2 hypertension) of patients with hypertension and type 2 diabetes enrolled in an open-label, single-arm study (n = 192). Patients started treatment with OM 20 mg/day and were uptitrated at 3-week intervals to OM 40, OM/HCTZ 40/12.5, and OM/HCTZ 40/25 mg/day if BP was ≥120/70 mmHg. The primary endpoint was the change in mean 24-hour ambulatory SBP from baseline to week 12, assessed by mean 24-hour ambulatory BP monitoring. Secondary endpoints included changes in mean 24-hour ambulatory DBP, mean daytime ambulatory BP, mean nighttime ambulatory BP, and mean office seated BP, and the proportions of patients achieving prespecified ambulatory BP targets.

SETTING

This was a multicenter study (24 sites) that took place between November 2006 and November 2007 in the US.

RESULTS

BP reductions were significant (p < 0.0001) and similar among subgroups of patients with type 2 diabetes. Following dose titration to OM/HCTZ 40/25 mg/day, similar proportions of patients in the age, race, and sex subgroups (approximately 60-64% across these subgroups) achieved an ambulatory BP target of <130/80 mmHg. A larger proportion of patients with type 2 diabetes and stage 1 hypertension achieved this same goal compared with patients with stage 2 hypertension (75% vs 46.3%). The combination of OM/HCTZ was well tolerated in all patient subgroups irrespective of age, race, sex, or hypertension severity.

CONCLUSIONS

In this open-label study, OM/HCTZ combination therapy was efficacious and well tolerated in subgroups of patients with diabetes and hypertension. [Clinical Trials Registry Number: NCT00403481].

Renin-angiotensin-aldosterone system blockade effects on the kidney in the elderly: benefits and limitations

The proportion of the population that is elderly (age>or=65 years) is growing across the world. The increasing longevity of humans results in a higher number of elderly patients' presenting with multiple chronic diseases such as hypertension, diabetes, and chronic kidney disease (CKD). These problems increase morbidity and mortality in the elderly. Overactivity of the renin-angiotensin-aldosterone system (RAAS) is associated with the development of hypertension, cardiovascular events, and CKD, so targeting the RAAS is a logical therapeutic approach. Elderly patients present special concerns regarding the benefits versus risks of using RAAS blockers. Plasma renin activity declines with age, which has been attributed to the effect of age-associated nephrosclerosis. Plasma aldosterone is also reduced with age, resulting in a greater risk for hyperkalemia in older individuals, especially when coupled with the age-associated decline in GFR. Moreover, the elderly have a higher frequency of concurrent conditions and are on many medications, which may further increase the risk for adverse effects of RAAS blocking agents. Unfortunately, there is a paucity of literature that is specifically aimed at studying elderly using the RAAS blockers. We present in our in-depth review data regarding benefits and limitations of the use of the RAAS blockades on the various sites along the RAAS pathway for elderly patients. Specific attention was given to the role of combination RAAS blockade therapy and higher monotherapy dosing in the treatment of hypertension in the elderly.

Efficacy of an olmesartan medoxomil-based treatment algorithm in patients stratified by age, race, or sex

Demographic factors are known to influence the prevalence of hypertension, and evidence suggests that they may also influence the response of patients with hypertension to blood pressure (BP)-lowering therapies. To determine the effect of demographic factors on the efficacy and safety of an olmesartan medoxomil (OM)-based treatment regimen, we performed a prespecified subgroup analysis of a 12-week, randomized, placebo-controlled, titrate-to-goal study in patients with hypertension, stratifying patients into treatment groups according to age, sex, or race. After 12 weeks, OM-based therapy significantly reduced BP from baseline in blacks, non-blacks, men, women, and patients younger than 65 or 65 years and older compared with placebo, and enabled 51.9% to 79.5% of patients to achieve a BP goal of <140/90 mm Hg. The differences in BP-lowering efficacy of OM-based therapy between subgroups were not clinically significant, and treatment was generally well tolerated in all groups. This study demonstrates that an OM-based treatment algorithm is an effective and safe option for achieving recommended BP goal in patients with hypertension including blacks, non-blacks, men, women, and patients younger than 65 or 65 years and older.