Low-Dose Combination Therapy for Initial Treatment of Hypertension
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ANTIHYPERTENSIVE AGENTS: MECHANISMS OF DRUG ACTION (ME ERNST, SECTION EDITOR)
Low-Dose Combination Therapy for Initial Treatment of Hypertension Emily R. Atkins 1,2 & Clara K. Chow 1,2,3
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review To summarise the advances that have been made from 2017 in dual, triple, and quadruple low-dose combination therapy for treating high blood pressure. Recent Findings Many people require multiple blood pressure lowering medicines to achieve target blood pressures, and initiating treatment with combination blood pressure lowering therapy is being increasingly investigated and recommended. Low-dose combinations of blood pressure lowering provide more effective blood pressure lowering, with fewer adverse events. Recent advances include listing of four dual combinations on the WHO Essential Medicines List, completion of a triple half-dose combination trial, and a pilot of quadruple quarter-dose combination, and recent cardiovascular polypill trials have included two blood pressure lowering medicines at low dose. These trials all demonstrated improvements in achieving blood pressure targets with low-dose combination therapy. Summary Low-dose combination therapy is a promising option for initial treatment of hypertension that appears to be safe and effective. Larger trials of triple and quadruple low-dose combination therapy in multiple locations are underway and should provide stronger evidence of efficacy as well as information on the side effect profile. Keywords Hypertension . Blood pressure . Low-dose combination . Fixed-dose combination . Polypill . Adherence
Introduction High blood pressure, hypertension, remains the leading modifiable risk factor for the global burden of disease and disability [1], with significant gaps in awareness, treatment, and control in all regions and World Bank income levels [2, 3]. Despite many blood pressure lowering medicines available, with the majority being off-patent and manufactured as generics, there are significant barriers in terms of availability, affordability, and use of these medicines globally [4]. This article is part of the Topical Collection on Antihypertensive Agents: Mechanisms of Drug Action * Clara K. Chow [email protected] 1
The George Institute for Global Health, UNSW, Sydney, Australia
2
Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
3
Department of Cardiology, Westmead Hospital, Rm No 2041, Westmead, Sydney, NSW 2145, Australia
Previously, hypertension treatment guidelines have recommended initiating treatment with a single blood pressure lowering agent at standard dose, with up-titration to maximal dose before adding a second agent. However, single agents at a standard dose achieve an average reduction of 9.1 mmHg [5•], which for many is insufficient to achieve control. Globally, the PURE study found that most participants being treated are on monotherapy (69.2%), and less than a third of those treated achieve
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