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Analysis: Combo First for Blood Pressure

Posted on: Saturday, 20 May 2006, 03:06 CDT

By ED SUSMAN

The take home message for doctors who treat the 65 million Americans with high blood pressure: Start with combination therapy because that gets blood pressure to normal levels, fast and safely.

In a series of new clinical trials, the superiority of combination treatment was shown time and again, and more concerning, Paul Ridker, professor of medicine at Brigham and Women's Hospital/Harvard Medical School, Boston, told United Press International: If a patient starts on single drug therapy and later switches to a combination regimen, the patient's blood pressure never gets quite as low as it could have been.

People with high blood pressure have increased risks of stroke, heart attacks and kidney failure and getting blood pressure to normal levels can prevent those medical catastrophes.

Ridker reported Friday at the annual meeting of the American Society of Hypertension (high blood pressure) in New York City, how treating patients with valsartan (Diovan), a drug known as an angiotensin receptor blocker, can markedly lower blood pressure in patients who have hypertension. More importantly, people who take valsartan with a standard diuretic - a water pill - can significantly lower blood pressure even further.

In fact, nearly half the patients taking the combination in his study were able to achieve their blood pressure goal, whereas just 32 percent of people on the single pill were able to get their blood pressure down to levels sought by their doctors.

Joel Neutel, medical director of the Orange County Heart Institute and Research Center, Orange, Calif., showed in another study that when the drug amlodipine (Norvasc) is added to either an angiotensin-converting enzyme inhibitor quinapril (Accupril) or the angiotensin receptor blocker losartan (Cozaar) more patients are able to reach their blood pressure goals than taking the individual drugts alone.

His study scrutinized how diabetic patients with high blood pressure fared with monotherapy and combination therapy: The winner again was the dual drug treatment.

In Neutel's study 27.5 percent of these hard-to-treat patients whose blood pressure goals are lower than other people without the complication of diabetes reached their goal of getting pressure under 130/80 millimeters of mercury (mmHg). Only 12.5 percent of those on a single drug reached the goal.

Clearly two drugs are better than one, Neutel told UPI during a press briefing, but that still means the vast majority of people still are not reaching their goal. With many of these people we will need three or four drugs. He said his choice for a third drug in these patients would likely be a diuretic.

In two other studies, doctors examined the blood pressure-lowering effects of using a combination of medication to lower blood pressure and another to lower cholesterol. John Kostis, professor of medicine and pharmacology at the University of Medicine and Dentistry of New Jersey, New Brunswick, said as many as half the people with high blood pressure also have high cholesterol - another major risk factor for heart disease.

He reviewed data in the TNT (Treating to New Targets) study and determined that patients who were had the lowest cardiovascular incidents - heart attacks, strokes or the need for urgent medical procedures to relieve chest pain - had the lowest levels of bad cholesterol and their blood pressure that was under control.

His patients were treated with a combination of Norvasc and atorvastatin (Lipitor).

The same drugs were used by John Flack, professor of medicine at Wayne State University, Detroit, in a trial in of African Americans. These individuals with mild, moderate and sever high blood pressure were treated with Caduet, a pill containing both Norvasc and Lipitor in one package.

Overall, using the Caduet regimen, 48.3 percent of patients was able to reach their goals of controlling blood pressure and controlling cholesterol. He said that 73.7 percent of patients achieved national cholesterol level goals and 56.8 percent achieved their blood pressure goal.

Why don't we just cut to the chase and begin treatment of these patients with a combination drug? asked Jan Basile, professor of medicine at the Medical University of South Carolina, Charleston. Basile moderated a panel that reviewed the studies.

Flack told UPI that too often doctors prescribe a drug to patients and for one reason or another don't increase or change the prescription even when the patient seems to have stopped making progress against high blood pressure.

We need to overcome physician inertia, he said. It is clear that even in difficult to treat groups such as diabetics and African Americans we can get their blood pressure under control but therapeutic inertia is a huge problem in cardiovascular management.

Source: United Press International

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