Современная стратегия в лечении артериальной гипертонии: комбинированная терапия и фиксированные комбинации

Abstract

The introduction of fixed combinations for the treatment of arterial hypertension (AH) is an effective strategy to address the public health burden of cardiovascular disease. This strategy is reflected in modern international guidelines for the treatment of AH and is supported by World Health Organization. The use of fixed combinations allows solving key practical problems to achieve better results and improve the prognosis of AH: ensuring the greatest decrease in blood pressure (BP) and a lower target BP level, shortening the time period for obtaining target BP, increasing adherence to treatment. Fixed combinations include classes of antihypertensive drugs, which, when combined, have an additive or synergistic effect in lowering BP, help to reduce/mitigate side effects, reduce the number of pills and increase patient adherence, solving the problem of polypharmacy. Single dosing per day of fixed combinations is another important benefit, providing adherence, longer duration of action, and reduced diurnal fluctuations in BP. The clinical benefits of fixed combinations have been confirmed in a number of large studies and meta-analyzes. The modern tactics of using fixed combinations provides for their use at different stages/degrees of BP increase. In this regard, fixed combinations with subtherapeutic, therapeutic and maximum therapeutic doses of components have been developed. For the use of fixed combinations as an initial therapy for AH, drugs with subtherapeutic doses of components that are not used in monotherapy are proposed. In such cases, thanks to the complementary selection of combined drugs, it is possible to achieve a more significant and timely BP reduction, with fewer side effects. Modern fixed combinations are based on three main classes of antihypertensive drugs – RAAS blockers (ACE inhibitors and ARBs), calcium antagonists and diuretics. There are 2 principal approaches to combinations: a combination of RAAS blockers with diuretics (diurethic-use) or a combination of RAAS blockers with calcium antagonists (diuretic-free). This preference is due to evidence-based medicine data, including questions of efficacy, tolerability, side effects, and confirmation in clinical trials. In the clinical guidelines for the treatment of hypertension, these combinations are considered preferred (evidence level A). Over time, more and more fixed combinations become generic and reliable generic combination drugs for the treatment of hypertension appear, which reduces the cost factor and makes the therapy economically acceptable.