Hypertension control with angiotensin II receptor blockers: strategies utilizing titration and combination

Abstract

Recommended BP goals must be achieved to provide hypertensive patients with maximal protection from CV disease. Less than one third of hypertensive patients achieve goal BP, and so remain at significant risk for CV disease. Angiotensin II receptor blockers (ARBs) provide antihypertensive efficacy similar to that of other antihypertensive classes, but have better patient acceptance. In integrated analyses of controlled clinical trials, olmesartan medoxomil, the newest ARB, demonstrated 24-h BP control with dose-related efficacy and a tolerability profile similar to that of placebo. Titration from the starting 20-mg/d dose to the maximum 40-mg/d dose resulted in an incremental reduction in BP of 5.7/4.7 mm Hg, with no increase in adverse events. In head-to-head comparative trials, olmesartan medoxomil has been shown to provide antihypertensive efficacy equal to that of amlodipine besylate and atenolol, and to compare favorably with other leading ARBs. Olmesartan medoxomil was also studied in combination with hydrochlorothiazide (HCTZ), resulting in placebo-subtracted BP reductions of up to 24/14 mm Hg. A 24-wk study assessed BP control rates achieved with an olmesartan medoxomil-based treatment algorithm. Patients were initiated on olmesartan medoxomil 20 mg once daily. At subsequent 4-wk intervals, treatment was modified for subjects with BP >130/85 mm Hg: olmesartan medoxomil could be titrated to 40 mg/d; HCTZ (12.5-25 mg) could be added; and, finally, amlodipine (5-10 mg) could be added. Utilizing this algorithm, >90% of patients achieved a BP goal of ≤140/90 mm Hg, and approximately 88% achieved a more aggressive goal of ≤130/85 mm Hg. Reductions in mean systolic and diastolic BP were 33.7 mm Hg and 18.2 mm Hg, respectively. The development and use of such drug algorithms may be an important contribution to improving BP control.