Efficacy of a Fixed-Dose Combination of Trandolapril-Verapamil in Patients with Stage 2 Hypertension Inadequately Controlled by Monotherapy

A Prospective Noninterventional, Observational Study to Describe the Effectiveness and Safety of Trandolapril and Verapamil Single-Pill Combination in the Management of Patients with Hypertension and Type 2 Diabetes Mellitus: A Harvest TR Study

Maintaining regular blood pressure control usually requires multidrug regimens rather than monotherapy. The objective of this study was to describe the effectiveness and safety of an angiotensin-converting enzyme inhibitor and a nondihydropyridine calcium channel blocker in a single-tablet combination in patients with hypertension, a heart rate higher than 70 beats/min, and type 2 diabetes mellitus (T2DM). This study was conducted in Turkey as a prospective, noninterventional, observational study. At 22 clinical sites, the data of 200 patients with hypertension were used for efficacy analysis; however, 262 patients received at least one dose of trandolapril/verapamil fixed-dose combination at two dose strengths. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate, PR interval, glycated haemoglobin (HbA1c), and albumin/creatinine ratios were recorded during 8 weeks of treatment. With treatment, the mean (±SD) SBP that was recorded as 162.8 (±14.642) mm Hg at baseline was reduced to 131.7 ± 11.1 mm Hg at week 8 (p < 0.05). Similarly, the mean DBP was reduced from 93.76 ± 9.16 mm Hg to 77.6 ± 7.6 mm Hg (p < 0.001). Following 8 weeks of treatment, SBP and DBP values were reduced below 140 mm Hg and 90 mm Hg in most patients (81.5%), respectively. The mean heart rate as evaluated using electrocardiography measurements was reduced to 78.25 beats/min at week 8 as compared with baseline during trandolapril/verapamil single-pill combination treatment (p < 0.001). Treatment with trandolapril and verapamil was well tolerated over 8 weeks with no unexpected safety signals. In conclusion, the single-pill combination of trandolapril and verapamil was considered effective in reducing and controlling blood pressure in patients with hypertension and T2DM. There was a significant improvement in HbA1c and ACR levels in a smaller subgroup of the patient cohort. The trandolapril/verapamil combination was evaluated as being safe and well-tolerated following a treatment period of 8 weeks. This trial was registered with NCT02298556.

Current concepts in combination therapy for the treatment of hypertension: combined calcium channel blockers and RAAS inhibitors

Recent guidelines for the management of hypertension recommend target blood pressures <140/90 mmHg in hypertensive patients, or <130/80 mmHg in subjects with diabetes, chronic kidney disease, or coronary artery disease. Despite the availability and efficacy of antihypertensive drugs, most hypertensive patients do not reach the recommended treatment targets with monotherapy, making combination therapy necessary to achieve the therapeutic goal. Combination therapy with 2 or more agents is the most effective method for achieving strict blood pressure goals. Fixed-dose combination simplifies treatment, reduces costs, and improves adherence. There are many drug choices for combination therapy, but few data are available about the efficacy and safety of some specific combinations. Combination therapy of calcium antagonists and inhibitors of the renin-angiotensin-aldosterone system (RAAS) are efficacious and safe, and have been considered rational by both the JNC 7 and the 2007 European Society of Hypertension – European Society of Cardiology guidelines for the management of arterial hypertension. The aim of this review is to discuss some relevant issues about the use of combinations with calcium channel blockers and RAAS inhibitors in the treatment of hypertension.

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

Poor control of clinic and 24-h blood pressure (BP) is associated with enhanced risk of all cardiovascular disease events. Certain patient groups including the elderly, African-Americans, and those with hypertension and comorbid disease are difficult to control, as are patients with stage 2 hypertension (systolic BP>or=160 mmHg or diastolic BP>or=100 mmHg). It has been estimated that more than two-thirds of high-risk hypertensive patients with stage 2 hypertension and all hypertensive patients with diabetes mellitus or kidney disease will require two or more antihypertensive agents from different therapeutic classes to reach BP goals. Combining agents with distinct and complementary modes of action can address different pathophysiologic mechanisms involved in hypertension and may lead to more complete and prompt reductions in BP. Tolerability may also improve, as certain classes of antihypertensive agents ameliorate adverse effects associated with other agents. Patients may benefit from fixed-dose combinations of drugs as this simplifies the regimen and may improve adherence with therapy, control of BP, and ultimately lead to reductions in cardiovascular events. Recent data and treatment guidelines support the use of a combination strategy as 'initial' antihypertensive therapy in high-risk patients with stage 2 hypertension.

The importance of prompt blood pressure control

Hypertension affects almost one-third of adults in the United States, but blood pressure is adequately controlled in only about 50% to 60% of persons with treated hypertension. Abundant clinical trial evidence has shown that antihypertensive therapy significantly reduces the risk of vascular events, and meta-analyses of observational and clinical trials have shown that greater reductions in blood pressure are associated with greater reductions in risk. Recent trials have also suggested that prompt control of blood pressure is beneficial in high-risk patients with hypertension. A post hoc analysis of a trial comparing an angiotensin II receptor blocker-based program with a calcium channel blocker-based treatment regimen found that the blood pressure response after 1 month (regardless of the drug used) predicted the risk of vascular events and survival. Therapy with > or =2 medications given separately or as a fixed combination is more likely than monotherapy to lower blood pressure to goal in part because drugs from different classes target different mechanisms that regulate blood pressure. Moreover, the likelihood of achieving blood pressure goals is greater if the time to achieve control is shortened, and prompt control of blood pressure is more likely with multiple-drug therapy than with monotherapy.

Prompt, aggressive BP lowering in high-risk patients

Various populations with hypertension have been singled out by current treatment guidelines as requiring more specific treatment. These include patients with stage 2 hypertension, black patients, and patients with coexistent diabetes mellitus and coronary heart disease. Hypertension in these groups is often associated with higher risk of cardiovascular morbidity and mortality. This article reviews current knowledge regarding hypertension in high-risk patient populations, with a particular focus on the importance of prompt, aggressive treatment to lower blood pressure and prevent cardiovascular disease progression. Such treatment includes the early use of multiple-drug therapy with agents that have complementary blood pressure-lowering mechanisms and provide protection from target organ damage. While 2- or 3-drug antihypertensive therapy in these high-risk groups has typically included a diuretic, other combinations of agents may be indicated. Evidence suggests that therapy with a calcium channel blocker and an inhibitor of the renin-angiotensin system is one effective strategy for lowering blood pressure and improving outcomes in these populations.