Combination Therapy In Hypertensive Patients Research Articles

Hypertension Medication from Guidelines to Practice: A Cohort study in western Iran.

Hypertension (HTN) is one of the most common risk factors for non-communicable chronic diseases. The aim of the current study is to evaluate the prescribing patterns of antihypertensive medications in Kermanshah Province, west of Iran. The Ravansar Non-Communicable Diseases (RaNCD) cohort study is the first Kurdish community-based study; subjects' age ranged from 35-65 years. In order to examine the use of medications to control blood pressure, participants were asked to bring all prescribed medications to the study center. Treatments were compared with 2013 European Society of Hypertension (ESH) / European Society of Cardiology (ESC) Guidelines for the management of arterial HTN RESULTS: From a total of 10,040 participants in RaNCD cohort, 1,575 (15.7%) individuals were hypertensive, of whom, 1271 ((80.7%) people were aware of their condition. From 1,153 (73.20%) people under treatment, 840 (72.8%) had their HTN properly controlled. The most common medications used to treat HTN were losartan (27.5%), metoprolol (14.3%), and captopril (11.9%). Regardless of type of treatment, 49.3% of all patients have received the medication for l 6≥years. The most commonly used drugs were β-Blockers and Angiotension receptor blockers as 620 (31.0%) and 612 (30.6%), respectively. Multivariable analysis showed that female gender, those receive ≥3 antihypertensive agents, and using preferred combinations were associated with a better blood pressure control. In addition, the chance of hypertension control was less likely with duration of treatment and in obese patients with BMI ≥ 35 kg/m2 . Even though adherence to the international guidelines was acceptable, improvements can be made for better control of HTN. Therefore, it is imperative to educate healthcare professionals on improving their selection of antihypertensive medications and combination therapy for hypertensive patients. This article is protected by copyright. All rights reserved.

Starting Antihypertensive Drug Treatment With Combination Therapy

Starting Antihypertensive Drug Treatment With Combination Therapy

Assessment of suitable antihypertensive therapies: Combination with high-dose amlodipine/irbesartan vs triple combination with amlodipine/irbesartan/indapamide (ASAHI-AI study).

Angiotensin receptor blockers (ARBs) plus calcium channel blockers (CCBs) are a widely used combination therapy for hypertensive patients. In order to determine which combination was better as the next-step therapy for standard-dose combination of ARBs and CCBs, a combination with high-dose CCBs or a triple combination with diuretics, the authors conducted a prospective, randomized, open-label trial to determine which of the following combination is better as the next-step treatment: a combination with high-dose CCBs or a triple combination with diuretics. Hypertensive outpatients who did not achieve their target blood pressure (BP) with usual dosages of ARBs and amlodipine 5mg were randomly assigned to treatment with irbesartan 100mg/amlodipine 10mg (Group 1: n=48) or indapamide 1mg in addition to ARBs plus amlodipine 5mg (Group 2: n=46). The primary end point was changes in the systolic BP (SBP) and diastolic BP (DBP) after the 12-week treatment period, while secondary end points were changes in BP after the 24-week treatment period and laboratory values. At 12weeks, the SBP/DBP significantly decreased from 152.1/83.4mmHg to 131.5/76.1mmHg in Group 1 and 153.9/82.1mmHg to 132.7/75.9mmHg in Group 2. Although both groups produced a similar efficacy in reducing the SBP/DBP (-19.2/-9.2mmHg in Group 1 and -21.6/-8.8mmHg in Group 2; SBP P=.378, DBP P=.825), high-dose CCBs combined with ARBs controlled hypertension without elevation of serum uric acid. These results will provide new evidence for selecting optimal combination therapies for uncontrolled hypertensive patients.

Cost Effectiveness Kombinasi Antihipertensi Candesartan-Bisoprolol dan Candesartan-Amlodipin Pada Pasien Rawat Jalan Penderita Hipertensi

Today, in various countries, especially in Indonesia, the cost of health services is increasing. Hypertension is a degenerative disease that requires health costs for a long time. Increasing costs due to increasing chronic diseases threaten access and quality of health services, by which it is necessary to find a solution to overcome the problem of health financing. One method used is to analyze the guidelines for hypertension therapy and drug classes in the pharmacoeconomic aspects, namely Cost Effectiveness Analysis. This study aims to analyze the effectiveness of antihypertensive combination therapy in hypertensive patients at Bhayangkara Hospital, Kendari in 2019. The research method is descriptive with cross sectional study design. The analysis conducted is the cost effectiveness analysis (CEA) performed by calculating direct medical costs, the effectiveness of therapy based on blood pressure that reaches the target and calculating the value of ACER (Average Cost Effectiveness Ratio) and ICER (Incremenal Cost Effectiveness Ratio). Data were collected prospectively which fulfilled the inclusion and exclusion criteria. The results showed the therapeutic effectiveness and the value of ACER obtained from 31 hypertensive patients were a combination of Candesartan – Bisoprolol that was ACER value of 85.71% (2,314), and combination of Candesartan – Amlodipin of 70.58% (2,643). ICER value of 7,832 indicates that the price of drugs is more expensive but more effective therapy.Keywords : cost effective, ACER, ICER, Hypertension, Candesartan, Amlodipin Abstrak: Dewasa ini, diberbagai negara khususnya di Indonesia biaya pelayanan kesehatan semakin meningkat. Hipertensi merupakan salah satu penyakit degeneratif yang membutuhkan biaya kesehatan dalam jangka waktu yang lama. Peningkatan biaya akibat semakin meningkatnya penyakit kronik mengancam akses dan mutu pelayanan kesehatan, olehnya itu perlu dicari solusi untuk mengatasi masalah pembiayaan kesehatan. Salah satu metode yang dilakukan yaitu dengan menganalisis pedoman terapi hipertensi dan golongan obat dalam aspek farmakoekonomi, yaitu Analisis Efektivitas Biaya. Penelitian ini bertujuan untuk menganalisis efektivitas terapi kombinasi antihipertensi pada pasien hipertensi di Rumah Sakit Bhayangkara Kendari tahun 2019. Metode penelitian ialah deskriptif dengan rancangan cross sectional study. Data diambil secara prospektif yang memenuhi kriteria inklusi dan eksklusi. Analisis yang dilakukan adalah cost effectiveness analysis (CEA) dilakukan dengan menghitung biaya medik langsung, efektivitas terapi berdasarkan tekanan darah yang mencapai target dan menghitung nilai ACER (Average Cost Effectiveness Ratio) dan ICER (Incremenal Cost Effectiveness Ratio). Hasil penelitian menunjukkan efektifitas terapi dan nilai ACER yang diperoleh dari 31 pasien hipertensi ialah kombinasi Candesartan – Bisoprolol yaitu nilai ACER sebesar 85,71% (2.314), dan kombinasi Candesartan – Amlodipin sebesar 70,58% (2.643). Nilai ICER sebesar 7.832 menunjukkan bahwa harga obat lebih mahal namun terapi lebih efektif. Kata Kunci : Efektivitas biaya, ACER, ICER, Hipertensi, Candesartan, Amlodipin

Associated Factors for Target Blood Pressure Achievement after Triple Combination Therapy in Hypertensive Patients

Associated Factors for Target Blood Pressure Achievement after Triple Combination Therapy in Hypertensive Patients

ASSESSMENT OF SUITABLE ANTIHYPERTENSIVE THERAPIES

Objective: Angiotensin receptor blockers (ARBs) plus calcium channel blockers (CCBs) are a widely used combination therapy for hypertensive patients. This study aimed to determine which combination was better as the next step therapy: a combination with high dose CCBs or a triple combination with diuretics. Design and method: We conducted a prospective, randomized, open-label trial. Hypertensive outpatients who did not achieve their target blood pressure (BP < 140/90mmHg) with usual dosages of ARBs and amlodipine 5 mg were randomly assigned to switch treatment to Irbesartan 100 mg/amlodipine 10 mg (group ARB+C: n = 30, aged 65 ± 14 years) or indapamide 1 mg in addition to ARBs+ amlodipine 5 mg (group ARB+C+D: n = 29, aged 68 ± 9 years). The primary endpoint was any change in the systolic blood pressure (SBP) and diastolic blood pressure (DBP) after the 3-month treatment period, while secondary endpoints were any change in the BP after the 6-month treatment period and laboratory values. We also evaluated the blood pressure variability including the seasonal variation in both groups. Results: At three months, the SBP/DBP significantly (p < 0.01) decreased from 150/80 ± 8/12mmHg to 132/73 ± 13/11mmHg in group ARB+C and 153/81 ± 11/14mmHg to 129/74 ± 16/12mmHg in group ARB+C+D. Similarly, at six months, the SBP/DBP significantly decreased to 132/74 ± 12/10mmHg in the ARB+C group, and to 128/73 ± 12/12mmHg in the ARB+C+D group. The serum potassium tended to decrease and uric acid to increase in the ARB+C+D group. When each treatment group was subdivided into four seasonal groups according to the season in which patients were assessed, there were no significant differences in the BP values between the four treatment groups. On the other hand, the visit-to-visit variability, evaluated by the SD or CV for the systolic BP, was higher in the ARB+C+D group than ARB+C group especially in the summer. Conclusions: High dose CCBs combined with ARBs and a triple combination with diuretics combined with CCB/ARBs produced a similar efficacy in reducing the BP. However, the change in the laboratory data and blood pressure variability were advantageous in the ARB+C group. The results from the ASAHI AI trial will provide new evidence for selecting optimal combination therapies for uncontrolled hypertensive patients.

Personalised Single-Pill Combination Therapy in Hypertensive Patients: An Update of a Practical Treatment Platform.

Despite the improvements in the management of hypertension during the last three decades, it continues to be one of the leading causes of cardiovascular morbidity and mortality worldwide. Effective and sustained reductions in blood pressure (BP) reduce the incidence of myocardial infarction, stroke, congestive heart failure and cardiovascular death. However, the proportion of patients who achieve the recommended BP goal (< 140/90 mmHg) is persistently low, worldwide. Poor adherence to therapy, complex therapeutic regimens, clinical inertia, drug-related adverse events and multiple risk factors or comorbidities contribute to the disparity between the potential and actual BP control rate. Previously we published a practical therapeutic platform for the treatment of hypertension based on clinical evidence, guidelines, best practice and clinical experience. This platform provides a personalised treatment approach and can be used to improve BP control and simplify treatment. It uses long-acting, effective and well-tolerated angiotensin receptor blocker (ARB) olmesartan, in combination with a calcium channel blocker amlodipine, and/or a thiazide diuretic hydrochlorothiazide. These drugs were selected based on the availability in most European Countries of single-pill, fixed formulations in a wide range of doses for both dual- and triple-drug combinations. The platform approach could be applied to other ARBs or angiotensin-converting enzyme inhibitors available in single-pill, fixed-dose combinations. Here, we present an update, which takes into account the results of the recently published studies and extends the applicability of the platform to common conditions that are often neglected or poorly considered in clinical practice guidelines.Electronic supplementary materialThe online version of this article (doi:10.1007/s40292-017-0239-7) contains supplementary material, which is available to authorized users.

PS 14-39 ROLE OF THE TRIPLE COMBINATION WITH INDAPAMIDE, NITRENDIPINE AND PERINDOPRIL IN RENAL PROTECTION

Objective: To study of antihypertensive and renoprotective efficacy of indapamide, nitrendipine and perindopril combination therapy in hypertensive patients with low estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2. Design and Method: The study included 20 patients with II-III stage of essential hypertension (ESH/ESC 2013) and eGFR<60 ml/min/1.73 m2 in average age 60.17 ± 7.86 yrs. All patients were resistant to previously bi-component antihypertensive therapy. Blood pressure (BP) measured by Korotkov method. GFR estimated by MDRD formula. Levels of serum creatinine, uric acid and glucose were measured with biochemical assay method. All measurements performed before and after 24 weeks of triple combination, based on indapamide, perindopril and nitrendipine in average dose 2.15 ± 0.56 mg, 4.72 ± 1.79 mg and 12.77 ± 5.65 mg respectively. Results: During the 24 weekly antihypertensive therapy with three drug combination systolic BP decreased from 160.0 ± 15.81 to 127.3 ± 11.8 mmHg (p = 0.0001), and diastolic BP – from 98.94 ± 8.11 to 79.3 ± 6.24 mmHg (p = 0.0001). Serum creatinine level was significantly decrease from 110.59 ± 20.69 to 93.4 ± 19.67 μmol/L (p = 0.01). Plasma glucose and uric acid levels had tendency to decrease: from 5.77 ± 1.16 to 5.71 ± 1.56 mmol/L and from 6.36 ± 1.99 to 5.76 ± 1.78 mg/dL (p > 0.05) respectively. eGFR was improved during the 24 weekly treatment and increased from 51.04 ± 6.81 to 62.58 ± 13.12 ml/min/1.73 m2 (p = 0.003), eGFR elevated >60 ml/min/1.73 m2 in 50% cases. All patients finished 24-weekly therapy with good tolerability. Conclusions: 24-weekly therapy with indapamide, perindopril and nitrendipine were characterized with high antihypertensive efficacy and good tolerability. Three drugs combination also had shown renoprotective effects with significantly increase of eGFR in hypertensive patients.

Efficacy and safety of calcium channel blocker/diuretics combination therapy in hypertensive patients: a meta-analysis.

Although recent guidelines recommend the combination of calcium channel blockers (CCBs) and thiazide (-like) diuretics, this combination is not widely used in clinical practice. The aim of this meta-analysis was to assess the efficacy and safety of this combination regarding the following endpoints: all-cause and cardiovascular mortality, myocardial infarction, and stroke. Four studies with a total of 30,791 of patients met the inclusion criteria. The combination CCB/thiazide (-like) diuretic was associated with a significant risk reduction for myocardial infarction (risk ratio [RR], 0.83; 95% confidence interval [CI], 0.73-0.95) and stroke (RR, 0.77; CI, 0.64-0.92) compared with other combinations, whereas it was similarly effective compared with other combinations in reducing the risk of all-cause (RR, 0.89; CI, 0.75-1.06) and cardiovascular (RR, 0.89; CI 0.71-1.10) mortality. Elderly patients with isolated systolic hypertension may particularly benefit from such a combination, since both drug classes have been shown to confer cerebrovascular protection.

A cross-sectional retrospective study to assess the pattern of prescribing for inpatient hypertensive cases in a tertiary hospital and to find out the possible avenues for betterment of hypertension management

Objective: The primary objective of this study was to characterize the prescribing pattern of antihypertensive agents in the tertiary care teaching hospital. The secondary objective of this study was to assess the appropriateness of the prescribing pattern of antihypertensive drugs as per the seventh report of the Joint National Committee (JNC-7) guidelines. Materials and Methods: A cross-sectional, retrospective study for the period of 7 months (June 2012 to January 2013) was conducted. Only inpatient hypertensive cases suffering from essential hypertension with or without other comorbid conditions were included in the study. Results: A total of 261 hypertensive patients on treatment, of which 57.9% were females and 42.1% males, were included. Hypertension alone was present in 26.8% of the patient whereas diabetes mellitus was the most common comorbid condition in 18.8% of the cases. Of the 261 patients studied, 47.1% were on monotherapy and 52.8% on combination therapy. The commonest monotherapy agents being prescribed were calcium channel blockers (CCBs) (26.8%), followed by diuretic (9.6%), angiotensin-converting enzyme inhibitor (ACEI) (5%), beta blockers (BBs) (3.8%) and angiotensin receptor blockers (ARBs) (1.9%). The commonest two drug therapy was with CCB and diuretic (15.7%), followed by CCB and BB (7.3%), CCB and ACEI (4.2%), ACEI and diuretic (3.4%), ARBs and diuretic (2.7%), BBs and diuretic (1.9%). The commonest three drug therapy was with CCBs, BBs, and diuretic (4.2%). Conclusion: The most favored class of antihypertensive drugs, either as monotherapy or combination therapy in hypertensive patients with or without comorbidities was CCBs. There was underutilization of thiazide diuretics, ACEIs and BBs in this study. Overall the general pattern of antihypertensive prescribing in this study is only partly in accordance with the guidelines of JNC-7.

Evaluation of effectiveness and safety of amlodipine/valsartan/hydrochlorothiazide single-pill combination therapy in hypertensive patients: an observational study

Objective:This study evaluated the effectiveness and safety of amlodipine/valsartan/hydrochlorothiazide (A + V + H) single-pill combination therapy in the treatment of hypertensive patients in daily practice.Design and methods:This prospective, open-label, observational study, enroled adults for whom their physician considered treatment with the single pill combination as indicated. The observational period per patient was ∼3 months. Results were evaluated using basic descriptive statistical methods.Main outcome:Data of 7132 patients were analyzed. At baseline, the mean blood pressure (BP) was 158.8 ± 17.7 mmHg (systolic, sBP) and 91.5 ± 10.7 mmHg (diastolic, dBP). The most common cardiovascular risk factors were positive family history, dyslipidemia, and diabetes mellitus. The most commonly used daily doses of A + V + H at study end were 5/160/12.5 mg (30.5%) or 10/160/12.5 mg (33.1%). At the last visit mean BP was 135.0 ± 11.8 mmHg (sBP) and 80.2 ± 7.3 mmHg (dBP). The mean BP reduction at last visit compared with baseline was −23.7 ± 17.5 mmHg (sBP) and −11.3 ± 10.6 mmHg (dBP); 43.5% of the patients reached normalization (BP <140/90 mmHg for non-diabetics or <130/80 mmHg for diabetics) and 71.3% reached therapeutic response (sBP <140 or ≥20 mmHg decrease vs baseline and dBP <90 or ≥10 mmHg decrease vs baseline in non-diabetic patients and sBP <130 mmHg or ≥20 mmHg decrease vs baseline and dBP <80 mmHg or ≥10 mmHg decrease vs baseline in patients with diabetes). Adverse events (AEs) were recorded in 2.3% of the patients, the most frequent being peripheral edema (0.6%) and dizziness (0.2%).Conclusions:In daily practice, A + V + H single-pill treatment effectively lowered the average BP in patients with essential hypertension and was well tolerated.

EFFICACY AND TOLERABILITY OF AMLODIPINE/TELMISARTAN COMBINATION THERAPY IN HYPERTENSIVE PATIENTS WITH CARDIOVASCULAR RISK FACTORS

ObjectivesMost patients with hypertension require more than one drug to attain recommended blood pressure (BP) targets. Initiating therapy with two agents is recommended for patients at high risk of a...

567 COMBINATION OF ANTIHYPERTENSIVE THERAPY IN THE ELDERLY, A MULTICENTER INVESTIGATIONAL (CAMUI) TRIAL

Background: Angiotensin receptor blockers (ARBs) with calcium channel blockers (CCBs) or diuretics are a widely used combination therapy for hypertensive patients. The present study aimed to determine which combination is better for elderly hypertension patients. Methods: We conducted a prospective, randomized, open-label trial in hypertensive outpatients aged ≧65 years who did not achieve the target blood pressure (BP < 140/90mmHg) with usual dosages of ARBs. Participants were randomly assigned to switch treatment to losartan 50 mg/hidrochrothiazide 12.5 mg (group ARB + D: n = 74) or amlodipine 5 mg in addition to ARBs (group ARB + C: n = 68). We evaluated the change in the BP, albuminuria, laboratory values and cognitive function. Results: The systolic BP/diastolic BP significantly decreased from 156/83 ± 15/11 mmHg to 138/75 ± 13/10mmHg (at 3 months) and 130/73 ± 17/11mmHg (at 12 months) in group ARB + D, and from 155/83 ± 11/10mmHg to 132/72 ± 14/10mmHg (at 3 months) and 132/73 ± 15/9mmHg (at 12 months) in group ARB + C. At 12 months, the urine albumine/creatine ratio significantly decreased from the geometric mean (GM) of 17.1 (95%CI: 11.0 – 26.6) mg/g to 8.6 (5.9 – 12.3) mg/g in group ARB + D, whereas it increased from the GM of 19.0 (12.1 – 29.7) mg/g to 23.7 (16.5 – 34.0) mg/g in group ARB + C. There was no significant difference between the 2 groups regarding the eGFR level and mini-mental state examination values at baseline and after one year. Conclusions: In the combination therapy with ARBs, diuretics might be superior to CCBs with respect to the renoprotecitve effects in elderly hypertension patients.

Combination of Antihypertensive Therapy in The Elderly, Multicenter Investigation (CAMUI) Trial

Angiotensin receptor blockers (ARBs) with calcium channel blockers (CCBs) or diuretics are a widely used combination therapy for hypertensive patients. The present study aimed to determine which combination was better for elderly hypertension patients aged ≧ 65 years.We designed a multicentre, randomized, open-label, parallel comparison study. Hypertensive outpatients aged ≧ 65 years who did not achieve the target blood pressure (BP < 140/90 mmHg) with usual dosages of ARBs were randomly assigned to switch treatment to losartan 50 mg/hydrochlorothiazide 12.5 mg or amlodipine 5 mg in addition to ARBs. The primary endpoint was a change in the systolic blood pressure (SBP) and diastolic blood pressure (DBP) after the 3-month treatment period, while secondary endpoints were changes in the BP, albuminuria, laboratory values, and cognitive function with the mini-mental state examination (MMSE) at baseline and after one year. The results from the CAMUI trial should provide new evidence for selecting optimal combination therapies for elderly hypertensive patients.

高血圧治療薬の併用療法：ARBとCCB併用による臓器保護効果

高血圧治療薬の併用療法：ARBとCCB併用による臓器保護効果

Abstract P55: Comparison of Real World Adherence, Healthcare Resource Utilization, and Cost for Valsartan/Amlodipine Single Pill Combination versus Angiotensin-Receptor Blocker/Calcium-Channel Blocker Free Combination Therapy

Objective: To evaluate adherence, healthcare resource utilization and cost outcomes of valsartan/amlodipine single pill combination (SPC) versus angiotensin-receptor blocker (ARB)/calcium-channel blocker (CCB) free combination (FC) therapy in hypertensive patients. Methods: A retrospective database study was conducted using a large US commercial insurance claims database for the period 01/01/2007-04/30/2008. Two cohorts of patients receiving valsartan/amlodipine SPC or ARB/CCB FC were identified. All patients were ≥18 years old with at least 1 medical claim for hypertension (ICD 9 401.x-404.x) with ≥6 months pre- and ≥12 months post-index follow up and ≥2 filled prescriptions with days supply ≥90 days for the index therapy over follow up. Primary outcomes were proportion of days covered, days to discontinuation (defined as a gap in therapy of 30 days), and all-cause healthcare cost and utilization. Multivariate regression analysis was conducted to control for baseline characteristics, including age, gender, region, comorbidities, pill burden, and resource utilization and cost. Results: A total of 3259 (13.1%) of patients were included in the valsartan/amlodipine SPC cohort and 21,597 (86.9%) in the ARB/CCB FC cohort. At baseline, patients taking SPC were more likely to be male, older, and reside in the Southern US. After adjusting for baseline differences through risk-adjusted logistic regression, adherence rates for patients taking SPC therapy were significantly higher compared to patients taking FC therapy (OR 1.38, 95% CI 1.27-1.51). Patients taking SPC therapy were also significantly less likely to discontinue their index therapy (HR 0.87, p&lt;0.001). Total all-cause health care costs were 11% greater for patients in the FC cohort compared to patients taking SPC therapy (p&lt;0.001). In addition, patients in the SPC cohort were less likely to have ER visits and hospitalizations during the follow up period. Conclusion: Use of valsartan/amlodipine single pill combination therapy in hypertensive patients was associated with significantly better adherence and lower cost and healthcare resource utilization compared to ARB/CCB free combination therapy.

Efficacy and Tolerability of Long-Acting Nifedipine GITS/OROS Monotherapy or Combination Therapy in Hypertensive Patients

Achieving the maximum reduction in cardiovascular morbidity and mortality is the primary goal of blood pressure (BP) control. Current guidelines recommend several antihypertensive classes as first-line therapy for this purpose but the decision on which agent/s to use will likely be based upon the treating physician's clinical experience. Observational studies provide a useful way of ascertaining the efficacy and tolerability of an antihypertensive in a real-life clinical setting. The aim of this observational study was to determine the efficacy, tolerability and physician/patient satisfaction with long-acting nifedipine (gastrointestinal therapeutic system [GITS]/osmotic-controlled release oral delivery system [OROS]) in a large multinational cohort of hypertensive patients. This observational study was conducted in adults (aged ≥18 years) with previously untreated or treated hypertension. The decision to prescribe nifedipine 30 or 60 mg once daily was made by the treating physician. Patients then attended up to three clinic visits any time over a 12-week period when medication could be up- or down-titrated or switched. The mean reduction in systolic BP (SBP)/diastolic BP (DBP) from first visit and whether target BP (<140/<90 mmHg or <130/<80 mmHg [for patients with diabetes mellitus]) had been achieved were recorded at the final visit and stratified according to hypertension grade and presence of cardiovascular risk factors. Subjective assessment of efficacy was reported by physicians and patients. All adverse events and their possible relationship to study drug were recorded. All assessments were performed on patients who received at least one dose of nifedipine GITS/OROS. A total of 14 344 patients received nifedipine GITS/OROS treatment (58.7% male; 77.7% non-diabetic; mean age 57.5 years); 14 266 had at least one follow-up visit over a mean 10.2-week period, and 8000 patients had three visits over a mean 12-week period. Initially, 12 826 (89.4%) patients received nifedipine 30 mg, and 6912 patients (48.2%) overall received concomitant antihypertensive agents. The overall mean reduction in SBP/DBP was -27.7/-14.1 mmHg; BP reduction was linked to hypertension grade, age, the presence of five or more cardiovascular risk factors, and prior treatment. Target BP was achieved in 2485/7432 patients (33.4%) receiving nifedipine GITS/OROS monotherapy and in 1751/6912 (25.3%) receiving combination therapy (i.e. GITS/OROS plus any other antihypertensive agent). Non-diabetic patients with moderate (n = 3413) and high (n = 1138) risk reached their target BP goal in 62.5% and 54.2% of cases, respectively; the corresponding values in diabetic patients (moderate-added risk n = 8; high-added risk n = 684) were 75.0% and 54.8%, respectively. A total of 229 patients (1.6%) reported experiencing 286 adverse events. Physician/patient satisfaction with treatment was high. Long-acting nifedipine GITS/OROS, alone or in combination with other antihypertensive agents, provides effective and well tolerated treatment of hypertension in a broad spectrum of patients routinely seen in day-to-day clinical practice.

Antihypertensive prescribing preferences in three South Indian Hospitals: cost analysis, physicians perspectives and emerging trends

The objectives of this study were i) to analyze the prescription pattern of antihypertensive agents in three South Indian hospitals ii) to perform cost-analysis of various antihypertensive treatment regimens iii) to examine the physicians' perspectives of antihypertensive prescribing. A cross-sectional study was done on patients with essential hypertension (n = 2,100) by analyzing the medical records of the patients for the drugs prescribed and patient demographics. Cost comparisons were made for the most frequently prescribed agents for each class at the most frequently prescribed dose and regimen. A questionnaire was developed containing questions on familiarity with guidelines, diagnosis of clinical hypertension, an evaluation of patients and choice of drug, and was distributed to physicians in the three hospitals. About one-half of the patients received monotherapy where the remaining received combination therapy for their hypertension. Calcium channel blockers (CCBs) were the most preferred agents used, either as monotherapy or combination therapy in hypertensive patients with or without comorbidities. At the most frequently prescribed dose and dosage regimen, thiazide was the least expensive antihypertensives, followed by CCBs. Physician's responses favored the use of CCBs as first-line agent for uncontrolled hypertension and a two-drug combination approach. The preference of CCBs and combination-therapy over the traditionally used diuretics or beta-blockers is consistent with the outcomes of recent clinical trials that underscore the benefits of using combination therapy with CCBs as initial therapy for uncomplicated hypertension.

Combination Therapies to Treat Hypertensive Patients with CKD

The need for combination therapy in hypertensive patients with chronic kidney disease (CKD) should require no elaboration. This is particularly true when considering the need to achieve the lower blood pressure goals (&lt;130/80 mmHg) recommended by most guidelines for patients with CKD. Mean number of antihypertensives required to achieve this blood pressure goal in renal outcome trials is between 3.5 and 4 agents. However, the benefit of inhibitors of renin angiotensin system (RAS) shown in multiple renal outcome trials makes their inclusion in the antihypertensive regimen in hypertensive patients with CKD obvious. Adequate diuresis is required to achieve blood pressure goal. In addition, in the ALLHAT trial, the thiazide‐type diuretic, chlorthalidone, was found to be at least as effective as the ACE inhibitor, lisinopril, in slowing progression of renal disease regardless of diabetic status (including the metabolic syndrome) and stage of kidney disease. Although calcium channel blockers in renal outcome trials have been shown to be less effective than RAS inhibitors in slowing the progression of CKD, their efficacy in blood pressure lowering generally requires their inclusion in the regimen. In addition, no loss of renal protection is seen when they are combined with RAS inhibitors. In those with estimated GFR &lt; 40 ml/min/1.73m2, loop diuretics should replace thiazide‐type diuretics in antihypertensive drug combinations, though indapamide and metolazone may retain some efficacy if volume status is not an issue. While some earlier studies suggested additive benefit of multiple RAS inhibitors on renal outcomes, recent large renal outcome trials have failed to confirm this benefit.

Efficacy and tolerability of amlodipine/valsartan combination therapy in hypertensive patients not adequately controlled on amlodipine monotherapy

Objective:This study was designed to explore antihypertensive efficacy and safety of a combination of amlodipine (CCB) and valsartan (ARB), in essential hypertensive patients not adequately controlled by amlodipine monotherapy.Methods:This was a multi-centre, randomised, double-blind, active-controlled study in patients with essential hypertension. After a washout period followed by a single-blind amlodipine 10 mg run-in period, patients with mean sitting diastolic blood pressure (msDBP) ≥90 mmHg and <110 mmHg were randomised to receive amlodipine/valsartan (10/160 mg o.d.) or amlodipine (10 mg o.d.) for 8 weeks.Trial registration number:NCT00171002.Main outcome measures:The primary efficacy variable was change from baseline in msDBP at study endpoint. Secondary efficacy variables were change from baseline in mean sitting systolic blood pressure (msSBP), responder rate (msDBP <90 mmHg or ≥10 mmHg reduction from baseline) and DBP control rate (msDBP <90 mmHg).Results:Of the 1283 patients enrolled in single-blind period, 944 were randomised to receive amlodipine/valsartan 10/160 mg (n = 473) and amlodipine 10 mg (n = 471). Statistically significant greater reductions (p < 0.0001) from baseline in msSBP/msDBP were observed with combination therapy (12.9/11.4 mmHg) compared to monotherapy (10.0/9.3 mmHg). Responder rate was significantly greater (p = 0.0011) with combination therapy (79.0%) compared to monotherapy (70.1%). The percentage of patients with controlled DBP was also significantly (p < 0.0001) higher with combination therapy (77.8%) compared to monotherapy (66.5%). Incidence of peripheral oedema was slightly higher with amlodipine monotherapy (9.4%) compared to combination therapy (7.6%).Conclusion:The combination of amlodipine/valsartan in this 8-week double-blind study provided additional BP control and was well tolerated in patients inadequately controlled with amlodipine monotherapy. Results should be interpreted with the knowledge that study entry criteria may limit application to a wider population.