Medication compliance and clinical outcomes of fixed-dose combinations vs free combinations of an angiotensin II receptor blocker and a calcium channel blocker in hypertension treatment

The 2022 focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension

Hypertension is the leading cause of death in human being, which shows high prevalence and associated complications that increase the mortality and morbidity. Controlling blood pressure (BP) is very important because it is well known that lowering high BP effectively improves patients' prognosis. This review aims to provide a focused update of the 2018 Korean Hypertension Society Guidelines for the management of hypertension. The importance of ambulatory BP and home BP monitoring was further emphasized not only for the diagnosis but also for treatment target. By adopting corresponding BPs, the updated guideline recommended out-of-office BP targets for both standard and intensive treatment. Based on the consensus on corresponding BPs and Systolic Blood Pressure Intervention Trial (SPRINT) revisit, the updated guidelines recommended target BP in high-risk patients below 130/80 mmHg and it applies to hypertensive patients with three or more additional cardiovascular risk factors, one or more risk factors with diabetes, or hypertensive patients with subclinical organ damages, coronary or vascular diseases, heart failure, chronic kidney disease with proteinuria, and cerebral lacunar infarction. Cerebral infarction and chronic kidney disease are also high-risk factors for cardiovascular disease. However, due to lack of evidence, the target BP was generally determined at < 140/90 mmHg in patients with those conditions as well as in the elderly. Updated contents regarding the management of hypertension in special situations are also discussed.

Fixed-dose Combination of Metoprolol, Telmisartan, and Chlorthalidone for Essential Hypertension in Adults with Stable Coronary Artery Disease: Phase III Study

INTRODUCTION

The aim of the study was to evaluate the efficacy and safety of fixed-dose combination (FDC) of metoprolol, telmisartan, and chlorthalidone in patients with essential hypertension and stable coronary artery disease (CAD) who showed inadequate response to dual therapy.

METHODS

In this phase III, open-label, multicenter study, 254 adults with stable CAD having uncontrolled hypertension despite being treated with FDC of metoprolol (25/50 mg) and telmisartan (40 mg) were included. Patients received either of the following FDC for 24 weeks: metoprolol (25 mg), telmisartan (40 mg), and chlorthalidone (12.5 mg) (FDC1; n = 139) or metoprolol (50 mg), telmisartan (40 mg), and chlorthalidone (12.5 mg) (FDC2; n = 115) tablets once daily. The FDCs were developed using the novel Wrap Matrix™ platform technology. Primary endpoint assessed the mean change in seated diastolic blood pressure (SeDBP) and seated systolic blood pressure (SeSBP) from baseline to 24 weeks. Secondary efficacy endpoints included proportion of patients achieving < 90 mmHg SeDBP (SeDBP responder) and < 140 mmHg SeSBP (SeSBP responder) at weeks 12, 16, 20, and 24. Safety was assessed throughout the study.

RESULTS

A total of 243 (95.70%) patients completed study. The mean change in BP from baseline (FDC1, 155/96 mmHg; FDC2, 165/98 mmHg) to week 24 (FDC1, 128/82 mmHg; FDC2, 131/83 mmHg) was statistically significant (both groups p < 0.0001). Within FDC1 and FDC2, the mean change from baseline to week 24 in SeDBP (82.60 mmHg and 83.09 mmHg) and SeSBP (128.07 mmHg and 131.29 mmHg) was statistically significant (both groups p < 0.0001). At week 24, in FDC1, 80.15% and 84.73% were SeDBP and SeSBP responders, respectively; in FDC2, 79.46% and 74.11% were SeDBP and SeSBP responders, respectively. No serious adverse events or deaths were reported.

CONCLUSION

Triple FDCs of metoprolol, telmisartan, and chlorthalidone were considered effective and well tolerated in patients with hypertension who respond inadequately to dual therapy.

CLINICAL TRIAL REGISTRATION

CTRI/2016/11/007491.

Major adverse cardiovascular event definitions used in observational analysis of administrative databases: a systematic review

Background

Major adverse cardiovascular events (MACE) are increasingly used as composite outcomes in randomized controlled trials (RCTs) and observational studies. However, it is unclear how observational studies most commonly define MACE in the literature when using administrative data.

Methods

We identified peer-reviewed articles published in MEDLINE and EMBASE between January 1, 2010 to October 9, 2020. Studies utilizing administrative data to assess the MACE composite outcome using International Classification of Diseases 9th or 10th Revision diagnosis codes were included. Reviews, abstracts, and studies not providing outcome code definitions were excluded. Data extracted included data source, timeframe, MACE components, code definitions, code positions, and outcome validation.

Results

A total of 920 articles were screened, 412 were retained for full-text review, and 58 were included. Only 8.6% (n = 5/58) matched the traditional three-point MACE RCT definition of acute myocardial infarction (AMI), stroke, or cardiovascular death. None matched four-point (+unstable angina) or five-point MACE (+unstable angina and heart failure). The most common MACE components were: AMI and stroke, 15.5% (n = 9/58); AMI, stroke, and all-cause death, 13.8% (n = 8/58); and AMI, stroke and cardiovascular death 8.6% (n = 5/58). Further, 67% (n = 39/58) did not validate outcomes or cite validation studies. Additionally, 70.7% (n = 41/58) did not report code positions of endpoints, 20.7% (n = 12/58) used the primary position, and 8.6% (n = 5/58) used any position.

Conclusions

Components of MACE endpoints and diagnostic codes used varied widely across observational studies. Variability in the MACE definitions used and information reported across observational studies prohibit the comparison, replication, and aggregation of findings. Studies should transparently report the administrative codes used and code positions, as well as utilize validated outcome definitions when possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01440-5.

Adherence to Single-Pill Versus Free-Equivalent Combination Therapy in Hypertension: A Systematic Review and Meta-Analysis

Poor adherence to antihypertensive therapy is a major cause of poor blood pressure (BP) control in patients with hypertension. Regimen simplification may improve adherence and BP control. This systematic review assessed whether single-pill combination (SPC) therapy led to improved adherence, persistence, and better BP control compared with free-equivalent combination (FEC) therapy in patients with hypertension. PubMed, Medline, Embase, and the Cochrane Library were searched until July 2020, in addition to manual searching of relevant congress abstracts from 2014 to 2020 for studies including adults with hypertension aged ≥18 years receiving SPC or FEC antihypertensive therapy measuring any of the following: adherence, persistence, and reductions in systolic BP and/or diastolic BP. Adherence and persistence were summarized in a narrative analysis; direct pair-wise meta-analysis was conducted to compare BP reductions with SPC therapy versus FEC therapy using fixed-effect and random-effects models. Following screening, 44 studies were included. The majority (18 of 23) of studies measuring adherence showed adherence was significantly improved in patients receiving SPCs versus FECs. Overall, 16 studies measured persistence, of which 14 showed that patients receiving SPCs had significantly improved persistence or were significantly less likely to discontinue therapy than patients receiving FECs. Systolic BP (mean difference, -3.99 [95% CI, -7.92 to -0.07]; P=0.05) and diastolic BP (-1.54 [95% CI, -2.67 to -0.41]; P=0.0076) were both significantly reduced with SPC therapy compared with FEC therapy at week 12. SPC therapy leads to improved adherence and persistence compared with FEC therapy and may lead to better BP control in patients with hypertension.

Is there any Hope for Monitoring Adherence in an Efficient and Feasible Way for Resistant Hypertension Diagnosis and Follow-Up?

PURPOSE OF REVIEW

Non-adherence to antihypertensive treatment is highly prevalent and represents a major factor affecting their effectiveness in hypertensive patients, thus contributing to apparent treatment resistance. It is however often overlooked because the methods to assess non-adherence are mainly subjective, limiting their usefulness in clinical practice. Non-adherence to treatment affects daily patient management, resulting in inappropriate, costly, and potentially harmful treatments and loss of the expected benefits from antihypertensive drugs.

RECENT FINDINGS

Specialized centers now use a combination of objective screening tools. Firstly, snapshots of adherence levels can be provided by analytical drug detection in various biological matrixes using liquid chromatography-tandem mass spectrometry (LC-MS/MS) and secondly electronic monitoring systems of drug delivery which provide longitudinal data on adherence. Routine utilization of those tools allows the detection of non-adherence in patients with resistant hypertension, thus enabling implementation of appropriate interventions to improve drug adherence and avoid unnecessary treatment intensification. Other complementary techniques, such as digital health feedback system with ingestible sensors, are currently evaluated. In the context of an increasing burden of uncontrolled and apparent treatment-resistant hypertension, detecting non-adherence to antihypertensive therapy is, as acknowledged by the latest guidelines, a top priority to implement in clinical practice but still faces medical conservatism and disbelief.

Does the Polypill Improve Patient Adherence Compared to Its Individual Formulations? A Systematic Review

Many patients, especially those with a high pill burden and multiple chronic illnesses, are less adherent to medication. In medication treatments utilizing polypills, this problem might be diminished since multiple drugs are fused into one formulation and, therefore, the therapy regimen is simplified. This systematic review summarized evidence to assess the effect of polypills on medication adherence. The following databases were searched for articles published between 1 January 2000, and 14 May 2019: PubMed, Web of Science, Cochrane Library, and Scopus. Medication adherence was the only outcome assessed, regardless of the method of measuring it. Sixty-seven original peer-reviewed articles were selected. Adherence to polypill regimens was significantly higher in 56 articles (84%) compared to multiple pill regimens. This finding was also supported by the results of 13 out of 17 selected previously published systematic reviews and meta-analyses dealing with this topic. Adherence can be improved through the formulation of polypills, which is probably why the interest in researching them is growing. There are many polypills on the market, but the adherence studies so far focused mainly on a small range of medical conditions.

2018 Korean Society of Hypertension Guidelines for the management of hypertension: part II-diagnosis and treatment of hypertension

The standardized techniques of blood pressure (BP) measurement in the clinic are emphasized and it is recommended to replace the mercury sphygmomanometer by a non-mercury sphygmomanometer. Out-of-office BP measurement using home BP monitoring (HBPM) or ambulatory BP monitoring (ABPM) and even automated office BP (AOBP) are recommended to correctly measure the patient’s genuine BP. Hypertension (HTN) treatment should be individualized based on cardiovascular (CV) risk and the level of BP. Based on the recent clinical study data proving benefits of intensive BP lowering in the high risk patients, the revised guideline recommends the more intensive BP lowering in high risk patients including the elderly population. Lifestyle modifications, mostly low salt diet and weight reduction, are strongly recommended in the population with elevated BP and prehypertension and all hypertensive patients. In patients with BP higher than 160/100 mmHg or more than 20/10 mmHg above the target BP, two drugs can be prescribed in combination to maximize the antihypertensive effect and to achieve rapid BP control. Especially, single pill combination drugs have multiple benefits, including maximizing reduction of BP, minimizing adverse effects, increasing adherence, and preventing cardiovascular disease (CVD) and target organ damage.

Long-Term Use of Tamoxifen Is Associated With a Decreased Subsequent Meningioma Risk in Patients With Breast Cancer: A Nationwide Population-Based Cohort Study

Background: Earlier studies have indicated a relatively higher risk of occurring meningioma among female breast cancer survivors and have suggested that tamoxifen might decrease this risk. The present study evaluated whether tamoxifen use in breast cancer patients can reduce the risk of meningioma.

Methods: We designed a population-based cohort study by using data from the National Health Insurance system of Taiwan to assess this issue. Between January 1, 2000, and December 31, 2008, women with breast cancer and of age ≥20 years were included. They were divided into two groups: those who had not received tamoxifen therapy and those who had. The Cox’s proportion hazard regression analysis was conducted to estimate the effects of tamoxifen treatment and the subsequent meningioma risk.

Results: We identified a total of 50,442 tamoxifen users and 30,929 non-tamoxifen users. Tamoxifen users had a borderline significantly lower overall risk of meningioma than non-tamoxifen users [adjusted hazard ratio (aHR) = 0.64, 95% confidence interval (95% CI) = 0.40–1.02]. A statistically significant difference was found in those patients with tamoxifen treatment duration longer than 1,500 days (aHR = 0.42, 95% CI = 0.19–0.91) or with cumulative dosage exceeding 26,320 mg (aHR = 0.44, 95% CI = 0.22–0.88). Furthermore, no statistically significant joint effect of aromatase inhibitors and tamoxifen on the occurrence of meningioma among breast cancer patients was seen.

Conclusion: Tamoxifen users had a non-significantly (36%) lower risk of developing meningioma than did tamoxifen non-users; however, our data indicated that tamoxifen therapy is associated with a reduced meningioma risk for Taiwanese breast cancer patients receiving long duration or high cumulative dosage treatment with tamoxifen.

Fixed-dose vs free-dose combinations for the management of hypertension-An analysis of 81 958 patients

Fixed-dose combinations (FDC) have been developed to reduce the pill burden for hypertensive patients. Data on fixed-dose or free-dose (freeDC) ramipril/amlodipine (R/A) or candesartan/amlodipine (C/A) combination treatment initiation were assessed. 71 463 patients were prescribed R/A and 10 495 C/A. For both R/A and C/A, FDC patients were younger (both P < .001) and less comorbid. Prior MI (OR: 0.61 and 0.60), prior stroke (OR: 0.68 and 0.70) and CHD (OR: 0.68 and 0.64) were negatively associated with FDC use, whereas hyperlipidemia was positively associated (OR: 1.26 and 1.19). Use of antihypertensive comedication (OR: 0.78; OR: 0.55) and treatment discontinuation within 12 months (HR: 0.65 and 0.82) were less likely in FDC patients, who also showed superior adherence (mean MPR; both P < .001). Cost of the combination was higher for FDCs (both P < .001). FDCs improve persistence and adherence, although they are more commonly prescribed in patients with less cardiovascular disease.

E4BP4 inhibits AngII-induced apoptosis in H9c2 cardiomyoblasts by activating the PI3K-Akt pathway and promoting calcium uptake

The bZIP transcription factor E4BP4 is a survival factor that is known to be elevated in diseased heart and promote cell survival. In this study the role of E4BP4 on angiotensin-II (AngII)-induced apoptosis has been examined in in vitro cell model. H9c2 cardiomyoblast cells that overexpressed E4BP4 were exposed to AngII to observe the cardio-protective effects of E4BP4 on hypertension related apoptosis. The results from TUNEL assays revealed that E4BP4 significantly attenuated AngII-induced apoptosis. Further analysis by Western blot and RT-PCR showed that E4BP4 inhibited AngII-induced IGF-II mRNA expression and cleavage of caspase-3 through the PI3K-Akt pathway. In addition, E4BP4 enhanced calcium reuptake into the sacroplasmic reticulum by down-regulating PP2A and by up-regulating the phosphorylation of PKA and PLB proteins. Our findings indicate that E4BP4 functions as a survival factor in cardiomyoblasts by inhibiting IGF-II transcription and by regulating calcium cycling.

Treatment adherence among adult hypertensive patients: a cross-sectional retrospective study in primary care in Romania

PURPOSE

This study was performed to elucidate the level of adherence to antihypertensive treatment in adult subjects attending a family medicine clinic in a city in central Romania.

PATIENTS AND METHODS

A cross-sectional, retrospective study was performed on a cohort of hypertensive adults. A total of 525 participants were selected from 1,714 adults attending a single urban family medicine practice. Assessment of adherence to therapy was performed by a chart review of prescription and clinical records over a 4-year study period.

RESULTS

The results showed that 69.8% of the patients had high adherence (>80% with therapy); 20.3% had medium adherence (20%-79%); and 9.9% had low adherence (<20%). A positive association was found (p = 0.01) between low adherence and male gender. A significant positive association (p = 0.02) was found between total cardiovascular risk and level of adherence. We found that 54.7% of the high adherence subjects had well-controlled blood pressure, and chronic kidney disease was associated with high adherence to therapy (p = 0.03). Antihypertensive regimens administered as fixed-dose combinations were positively associated with high adherence (p = 0.001). Subjects who had their antihypertensive regimen adjusted to a new drug class during the study period showed enhanced adherence compared to subjects treated with an unchanged regimen (p = 0.001).

CONCLUSION

This is the first published study assessing adherence to antihypertensive therapy in family medicine practice in Romania. It presented data derived from a primarily urban setting and targeted a geographical area where the prevalence of hypertension has increased continuously. Female gender, age, presence of cardiovascular risk factors, defined cardiovascular disease, chronic renal impairment, and good control of hypertension were positively associated with high adherence. The results provide insights to guide further strategies to improve adherence and indirect methods for blood pressure management strategies.