CLINICAL CARDIAC
BP CONTROL WITH CURRENT THERAPY
It has been shown that of those treated for hypertension , only 13 % had their blood pressure ( BP ) controlled .
Prof James Ker
There are many possible reasons for this but an emerging factor is the non-use of proven treatment strategies .
Monotherapy at increasing doses : Starting with monotherapy and then increasing the dose can be effective in reducing the blood pressure . However , as the dose increases , the side effects will increase .
This happens with diuretics , betablockers and calcium-channel blockers but not RAAS-blockers . There could be an exception when treating the very elderly , as more than one drug may increase hypotension and have serious side effects . One can start with a low dose and later increase the dose to first check that hypotension is not present . Sequential monotherapy : Trying to
The Boehringer Ingelheim
TRILOGY in Hypertension *
find the right monotherapy by switching from one to the other after a time on one is a very time-consuming strategy , which can make the patient lose confidence in the doctor and increase non-adherence .
Initial monotherapy and later combination therapy : Some guidelines support the strategy of initiating one drug with an effective
dose and then if control is not achieved , adding a second or even a third drug . This method is based on the rationale that due to different pathogenetic mechanisms , the drug combinations have a much greater BP-lowering capacity than monotherapy . This strategy makes it possible to increase the control rate from about one third in monotherapy to now two-thirds of hypertensive patients having controlled BP . It is thought that with different drugs , the different pathogenetic mechanisms are inhibited in a complimentary way . It is also possible to achieve control with lower doses of both or all of the drugs employed in the combination , which reduces the risk of side effects and increases the adherence rate .
Currently , the preferred combinations employ a RAAS-blocker ( ACE-Inhibitor or ARB ) with a diuretic such as indapamide , preferably , or a thiazide , or RAAS-blocker with a calcium channel blocker or a calcium channel blocker with a diuretic .
TELMISARTAN 40 / 80 mg
TELMISARTAN + HCTZ
TELMISARTAN + AMLODIPINE
FIRST AND ONLY ARB § INDICATED FOR THE REDUCTION OF MORTALITY & MORBIDITY 1 †
THE MOST COMMON SPECIALIST CHOICE
WHEN CHOOSING AN ARB § / HCTZ #
COMBINATION 2 ‡
COMPLIANCE RATES OF
≥ 98,4 %,
ONLY 19 % OF PATIENTS REQUIRING ADD-ON THERAPY 3
* Treatment in essential hypertension † For high cardiovascular risk patients ‡ Most commonly prescribed ARB / HCTZ single pill combination
§
ARB = Angiotensin Receptor Blockerer # HCTZ = Hydrochlorothiazide
References : 1 . MIMS July 2016 . 7.3.9 Angiotensin receptor antagonist ; 140-151 . 2 . Qlikview scripting data representing 85 % of the funded market . 3 . Neldam S , Edwards C , Lang M , et al . Long-Term Tolerability and Efficacy of Single-Pill Combinations of Telmisartan 40 – 80 mg Plus Amlodipine 5 or 10 mg in Patients .
S3 PRITOR ® 40 mg . Each tablet contains telmisartan 40 mg . Reg . No . 33 / 7.1.3 / 0022 . S3 PRITOR ® 80 mg . Each tablet contains telmisartan 80 mg . Reg . No . 33 / 7.1.3 / 0023 . S3 CO-PRITOR ® 40 / 12,5 mg . Each tablet contains telmisartan 40 mg and hydrochlorothiazide 12,5 mg . Reg . No . 35 / 7.1.3 / 0347 . S3 CO-PRITOR ® 80 / 12,5 mg . Each tablet contains telmisartan 80 mg and hydrochlorothiazide 12,5 mg . Reg . No . 35 / 7.1.3 / 0348 S3 TWYNSTA ® 40 / 5 mg tablets . Each tablet contains 40 mg telmisartan and 5 mg amlodipine base ( as besylate salt ). Reg . No . 44 / 7.1.3 / 0857 . S3 TWYNSTA ® 40 / 10 mg tablets . Each tablet contains 40 mg telmisartan and 10 mg amlodipine base ( as besylate salt ). Reg . No . 44 / 7.1.3 / 0858 . S3 TWYNSTA ® 80 / 5 mg tablets . Each tablet contains 80 mg telmisartan and 5 mg amlodipine base ( as besylate salt ). Reg . No . 44 / 7.1.3 / 0859 . S3 TWYNSTA ® 80 / 10 mg tablets . Each tablet contains 80 mg telmisartan and 10 mg amlodipine base ( as besylate salt ). Reg . No . 44 / 7.1.3 / 08 .
For full prescribing information refer to the package insert approved by the medicines regulatory authority . Applicant details : Ingelheim Pharmaceuticals ( Pty ) Ltd , 407 Pine Ave , Randburg , South Africa . Tel : + 27 ( 011 ) 348-2400 . Cpy . Reg . No . 1966 / 008618 / 07 . BI Ref No . GPM-TWPRICPR-0001-ZA .
Combination therapy first : Two-drug combination as an initial first step could be the preferred strategy . Some guidelines advocate this strategy when the initial blood pressure is ≥160 / 100mmHg . However , the authors state that they believe this strategy should be used more widely as the preferred initial step . Improvements in adherence rates have been demonstrated with single-pill combinations , which has variable doses and improve adherence rates .
Combination therapy is associated with more timely , faster and greater protective effects . In randomised trials , it was shown that the initial combination of a RAAS-blocker with a calcium channel blocker compared to monotherapy with the corresponding components , BP reductions were still visible after six weeks in the combination group . It took longer for the monotherapy components to catch up .
Initial combination treatment strategy may improve long-term BP control in a shorter time .
In two large cohorts , it was shown that initial combination treatment strategy discontinuation was significantly less . In two observational studies , starting with a combination strategy , there was much better cardiovascular protection with combinations from 26 % -34 %.
Many randomised blinded clinical trials in which BP was reduced to 140 / 90mmHg or less , the vast majority of patients needed a combination of drugs .
References available on request .
46 MAY 2017 | MEDICAL CHRONICLE