Efficacy and Safety Study of Olmesartan Medoxomil, Amlodipine, and Hydrochlorothiazide Combination Therapy in Patients with Hypertension Not Controlled with Olmesartan Medoxomil and Hydrochlorothiazide Combination Therapy: Results of a Randomized, Double-Blind, Multicenter Trial

Hypertension therapy using fixed-dose polypills that contain at least three medications

Fixed-dose combination (FDC) therapy may provide a solution to treatment gaps by overcoming reasons for therapeutic inertia. To synthesise and report on available evidence on standard or low-dose combination medicines that combine at least three antihypertensive medicines. A literature search was conducted via Scopus, Embase, PubMed and the Cochrane clinical trials database. Studies were eligible for inclusion if they were randomised clinical trials that included adults (>18 years) and examined the impact of at least three antihypertensive medications on blood pressure (BP). A total of 18 trials (n=14 307) were identified that examined combinations of three or four antihypertensive medicines. Ten trials investigated the effect of a standard dose triple combination polypill, four the effect of a low-dose triple and four the effect of a low-dose quadruple combination polypill. The mean difference (MD) in systolic BP ranged from -10.6 to -41.4 for the standard dose triple combination polypill in comparison with 2.1 to -34.5 for dual combination; -9.8 to -20.6 for a low-dose combination polypill in comparison with a MD of -0.9 to -5.2 for placebo; -9.0 to -29.3 for a low-dose combination polypill compared with -2.0 to -20.6 for monotherapy or usual care. All trials reported similar rates of adverse events. Ten studies reported medication adherence, six reported >95% adherence. Triple and quadruple combination antihypertensive medications are effective. Studies of low-dose triple and quadruple combinations involving treatment naïve populations suggest initiating such combinations are safe and effective as first-line therapy for stage 2 hypertension (BP >140/90 mm Hg).

Real-World Effectiveness and Safety of a Single-Pill Combination of Olmesartan/Amlodipine/Hydrochlorothiazide in Korean Patients with Essential Hypertension (RESOLVE): A Large, Observational, Retrospective, Cohort Study

BACKGROUND

The efficacy and safety of a single-pill combination (SPC) of olmesartan/amlodipine/hydrochlorothiazide (OLM/AML/HCTZ) have been established previously through multiple studies. However, the real-world data in Korean patients are still limited. This study evaluated the effectiveness and safety of SPC of OLM/AML/HCTZ in a real practice setting in Korean patients with essential hypertension.

METHODS

This was an observational, retrospective, multi-center, non-comparative cohort study. Medical records of 9749 patients with essential hypertension who had been prescribed OLM/AML/HCTZ within 1 year of the study were analyzed. The primary outcome was the achievement rate (%) of the target blood pressure goal of a systolic blood pressure (SBP) of < 140 mmHg and a diastolic blood pressure (DBP) of < 90 mmHg following administration of OLM/AML/HCTZ. The secondary outcomes included the rate of BP control measured at each visit, the amount of BP reduction compared to the index date, and the prescribing patterns of OLM/AML/HCTZ. Safety and tolerability were assessed by the incidence rate of adverse events (AEs) and discontinuation.

RESULTS

In the effectiveness analysis set (n = 9604), the overall achievement rate of target BP was 82.56%. The mean SBP/DBP was significantly reduced compared to baseline at all visits (all p < 0.0001), with the greatest reduction occurring at week 2. The achievement rate of target BP was above 71%, regardless of the presence of risk factors (diabetes mellitus, DM; cardiovascular disease, CVD; chronic kidney disease, CKD). Patients with CVD and aged > 65 years showed a significantly higher achievement rate (p < 0.05). A significant relationship existed between the primary outcome and age (p < 0.0001). The achievement rate exceeded 74% in all different age groups. In the safety analysis set (n = 9661), AEs were reported in 8.46% of patients, with the most frequent AE being dizziness. Serious adverse events (SAEs) and unexpected adverse events (UAEs) occurred in 0.96% and 3.73% patients, respectively. This was consistent with the previously reported safety profile of OLM/AML/HCTZ. The majority of AEs were mild to moderate and resolved during the observation period. The discontinuation rate of OLM/AML/HCTZ due to AEs was 1.67%.

CONCLUSION

This study demonstrated significant effectiveness of OLM/AML/HCTZ in achieving target BP in Korean patients with essential hypertension. OLM/AML/HCTZ was well tolerated.

Efficacy and safety of triple versus dual combination blood pressure-lowering drug therapy: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVES

Most patients with hypertension need at least two drugs to achieve goal blood pressure. This systematic review assessed efficacy and safety of triple versus dual combination therapy for the management of hypertension.

METHODS

Publication databases, clinical trial registries and regulatory agency websites were searched until April 2018 for double-blind randomized controlled trials (RCTs) comparing triple with dual therapy of BP-lowering drugs, for at least 3 weeks, among patients with hypertension. Meta-analyses for efficacy and safety outcomes were performed using random-effects model. Regimen efficacy was predicted using the Therapeutic Intensity Score (TIS) and the Law et al. method (which predict dose doubling increases efficacy by 100% and around 20%, respectively), and compared with observed efficacy.

RESULTS

Fourteen RCTs (11 457 participants) were included. Overall, triple compared with dual therapy reduced BP by 5.4/3.2 mmHg (P < 0.001), and improved BP control by 58 versus 45% [relative risk (RR) 1.33 (95% CI 1.25-1.41)], whereas incidence of withdrawals because of adverse events were 3.3 versus 3.4% [RR 1.24 (95% CI 1.00-1.54), P = 0.05]. Law et al.'s method was superior to TIS in predicting differences in efficacy between triple and dual therapies. For patients uncontrolled on submaximal dose dual therapy, adding a third drug achieved on average approximately four times more BP reduction than doubling the dose of dual therapy component drugs (6.0/3.6 versus 1.5/0.8 mmHg, respectively).

CONCLUSION

Addition of a third drug is likely to be more efficacious without increasing adverse events, compared with increasing dose of existing dual therapy. Early use of triple therapy can significantly improve hypertension control.