Symposium on Role of Combination Therapy in Treatment of Hypertension


 PSIM Mid-Summer Conference
Symposium on Role of Combination
Therapy in Treatment of Hypertension

SWAT: Globally the prevalence of hypertension is increasing and a vast majority of the people suffering from it do not know about it. One of the studies showed that 46.4% of patients are aware of their hypertension and 40.6% are treated while only 13.1% are controlled. On the whole 35% of patients achieve the desired blood pressure despite the fact that this is an easily diagnosable and treatable condition. This was stated by Prof. Azizur Rehman Professor of Medicine at Rashid Latif Medical College. He was speaking at a symposium on Role of Combination Therapy in the treatment of Hypertension organized by Novartis Pakistan during the Pakistan Society of Internal Medicine Mid-Summer conference held here recently.

Continuing Prof. Azizur Rehman said that non-treatment of hypertension leads to stroke, heart failure and Ischemic Heart Diseases and all these complications should be treated. He then referred to the NICE Guidelines on management of hypertension and laid emphasis on life style changes but in addition patients do need medications as well. One can start with RASS blockers which can be the first choice. ARBs are better tolerated and they are also safe. One can initiate treatment with Amlodipine and the goal should be 140/90. However, in those patients who are suffering from CAD or diabetes, the goal should be 130/80. In step two one can start with amlodipine, calcium channel blocker while in step three one can also add diuretics to this combination. If need be one can also add Hydrochlorothiazide in a small dose. One can treat 75-80% of the patients with this combination. However, he reiterated that the treating physicians must ensure that the patients are taking the drugs. In step four, one can also add MRA to this combination. Alternatively one can add beta blocker. Almost 80% of patients, Prof. Azizur Rehman stated are not controlled by single drug and they need combination of two or three drugs.

Prof. Azizur Rehman, Prof. Tariq Waseem and Prof. Sajid Abaidullah photographed
during the PSIM Mid-Summer conference held at Swat recently.

Prof. Azizur Rehman further stated that one can also start with ACEIs/ARBs plus CCBs or diuretics as initial therapy but one must make sure that all patients are on combination therapy. High dose of a single drug will increase the side effects hence small dose of two or more agents is preferred. The number of pills the patient has to take also affects the adherence to therapy. Many patients particularly elderly are already taking too many drugs. Hence for convenience now  three agents in a single pill are available. There are various dose preparations which are made available by the industry and any one of them may suit your patient.

He then gave highlights of the Amlodipine/Valsartan trial which enrolled 9794 patients and it lasted for six months. There was 31% risk reduction. His conclusions were that Amlodipine plus Valsartan makes a good combination and patient’s adherence is better with one pill. Start treatment with two drugs i.e. ARB plus ACEIs plus CCBs and Thiazide diuretic and most patients with uncomplicated hypertension will be managed well.

Management of complicates
of Diabetes Mellitus

Prof.Tariq Waseem was the next speaker who discussed management of complications of diabetes mellitus. He pointed out that this small vessel disease is associated with increased mortality in acute phase. Diabetics have more mortality and more chances of recurrence, hence we need to redefine the diabetes care. It must be ensured that one achieves optimal glycemic control, no hypotension and Metformin has to be included in all treatments. He also pointed out that patients with kidney disease were not included in the UKPDS. One has to be careful about the GI side effects of Metformin. There is also risk of B12 deficiency and modest weight loss. It can also worsen neuropathy and cognition.

Continuing Prof. Tariq Waseem said that with the use of Vildagliptin there is no increase in congestive heart failure and there is 14% decrease in BNP. Cardiovascular benefits or safety of anti-diabetics was very important. EMPA Heart study showed reduction in LV mass. The drug selected for the treatment of diabetes, he opined, should also have cardio protective effect and offer safety.

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