NEW APPROACH TO TREATING HIGH BLOOD PRESSURE

For decades, the “step-wise care” approach to treating high blood pressure (HBP) was in vogue. This approach recommended starting with a single drug, gradually increasing the dose until the BP was under control or the maximum dose was reached. If the BP was still high, the treating physician added a second drug, and increased its dose until the BP was under control or the maximum dose was reached. If HBP persisted, the physician stepped up treatment with a third, or possibly 4th or 5th drug, using the same method of gradually increasing the dose. While this approach worked, taking 2, 3, or 4 drugs often led to poor adherence to therapy. Taking numerous pills has been shown to result in missed dosages, or unpleasant side effects. 

Now, a new approach is being recommended. Instead of taking 3 or 4 separate BP pills, a single pill containing 3 (or 4) antihypertensive drugs is given. The pills have graded doses. This means the pills contain gradually increasing amounts of the 3 (or 4) drugs. Patients are first given a quarter-strength pill which contains one quarter of the maximum dose of each of the 3 (or 4) drugs. If BP control is still not reached, the half-strength pill is used next, followed by the three-quarter strength, and full-strength pills, if needed. Using three (or 4) drugs at once takes advantage of lowering the BP by using three (or 4) mechanisms of BP lowering. 

For example, one frequently used 3-drug combination is an ARB (angiotensin receptor blocker), telmisartan, a CCB (calcium channel blocker) Amlodipine, and a diuretic, indapamide. Treatment is started with the lowest strength of the combo. The second strength has half the maximum dose of each component, the next has three fourths strengths of all three, and the last has maximum dosage strengths of the three drugs. Compared to the standard step-care approach, more patients reach normal BP levels with triple-combination pills in a shorter length of time. The 3-drug combo pills lower HBP by 3 different mechanisms. 

My routine always was to avoid combination drugs. My thought was using drugs separately it was easier to decide which drug was having adverse effects, and tell which drug was really working to lower BP. I now see the three-drug combo pill is the better way to go. They work faster, the dosage is simpler to titrate, and flexibility is easier than I thought before. Taking only one pill is also much easier than taking 3 or 4 different pills. 

Cost is a concern. Most BP drugs are available in generic form, but combining them into a single pill may incur a manufacturer’s cost. One can always take the three components separately, but that defeats the single vs. multiple pills argument. That would be an individual cost determination. 

Bottom line: single-pill combinations of 3 or 4 antihypertensive drugs seem to be the new approach forward in the management of high blood pressure. Four combinations, weakest to strongest, have been shown to achieve better control in a shorter length of time. 

Reference: Hughes S. New Hypertension Approach Hits Multiple Targets at Low Dose. Medscape Medical News 2024 September 27.