Perindopril, Indapamide and Amlodipine combination leads to significant reduction in SBP and DBP - Javed Akram


Hypertension Management Beyond 2020
Perindopril, Indapamide and Amlodipine 
combination leads to significant reduction 
in SBP and DBP - Javed Akram
Now single pill can be taken instead of 4 Insulin injections
a day to manage Type-2 diabetes - Dr. Asif Humayun
Side effects of SGLT2 include dehydration, DKA and
it should not be used in diabetic foot

Lahore: Proceedings of the PSIM conference on second day of the conference March 14th started with a Breakfast session sponsored by Servier Pharmaceuticals. It was devoted to Hypertension Beyond 2020. It was jointly chaired by Prof. Naeem Aslam and Prof. Sajid Abaidullah. Other members of the panel of experts included Prof.Aftab Mohsin, Bilal Mohyuddin, and Prof. Bilquis Shabbir.

Dr. Asif Humayun from UK was the first speaker whose presentation was on Role of Sulphonylureas in management of Type-2 diabetes mellitus beyond 2020. He discussed their safety and efficacy in the light of American Diabetic Association and ESAD Guidelines 2018. The issues which we need to look at include is it effective in HbA1c reduction, what about cardiovascular safety and does it prevent complications? Can they be the preferred choice in some cases? These are some of the questions which are often asked. Hypoglycaemia is an independent risk factor for cardiovascular disease. It is because of Hypo episodes that they get bad name but all sulphonylureas are not the same. Gliclazide is very safe and almost 90% of the patients use it and in UK it is preferred as compared to other sulphonylureas. With this weight gain was not significant. We can use it for normal renal protection as well. In case of eCGR below 45, SGLT2 have to be stopped. One in five patients cannot tolerate it. It is safe in patients with eGFR of >60. He then presented a few case histories. The incidence of MODY, he stated, is very high in Pakistan. He advised the physicians to try to find out where the problem is and then try to resolve it. Patients can now just take a pill instead of four insulin injections a day. Gliclazide is preferred over insulin. However, one should be careful about the risk of DKA and amputation with the use of SGLT2. Avoid Metformin below 30eGFR and do not use SGLT2 in diabetic foot, he remarked.

Prof. Javed Akram

Prof. Javed Akram Vice Chancellor UHS was the next speaker whose presentation was on the role of triple dose combination in management of hypertension. He pointed out that currently there are six billion people suffering from hypertension worldwide which is 33% of the world population. Only 3-29% of them are under control. In Pakistan 65% of our population is not diagnosed, only 32% are diagnosed of which only 3% of patients have their blood pressure under control. We need to focus on GPs and Family Physicians and if we utilize their services, we can control hypertension. For this we need to provide them incentives as was done in UK. Cardiovascular disease risk factors increase with blood pressure and age. Majority of the patients require more than two drugs for treatment of hypertension. Atleast three drugs are needed. If we just add Indapamide with other two antihypertensive drugs, it works wonders. This combination of polypill was used in more than two thousand patients in Paksitan which resulted in significant reduction in systolic and diastolic blood pressure. Just add Indapamide to the patients who are taking beta blockers, calcium channel blockers or ACE Inhibitors. Sixty percent of patients, he said, were not controlled with two drugs and in such a situation; one should not be reluctant to add the third drug. With the use of Polypill there was more than 63% reeducation in stroke, 48% reduction in IHD. Moreover compliance also improved with the use of polypill as the patient had to take just one pill which included ACE Inhibitor, Diuretic and a calcium channel blocker. This triple drug combination is preferred. If need be one can add another diuretic in some special cases and there is no harm.

PSIM organized its conference at Lahore recently. Photograph shows from (L to R) Prof. Aftab Mohsin, Dr. Bilal S. Mohyuddin, Prof. Bilquis, Prof. Naeem Aslam and Prof. Khalid Abaidullah chairing one of the sessions.

He then discussed in detail the mode of action of Perindopril, Indapamide and Amlodipine combination which leads to maximum reduction in SBP and DBP. The early morning spike is also best managed with this combination. He further stated that combination of Losartan is best ARB and it was his favourite. Its benefits are molecule specific. It results in 28% reduction in all cause mortality. CVD mortality is reduced by 43%; there is significant reduction in Heart Failure while Indapamide also improves metabolic profile. Addition of Amlodipine in this combination will reduce cough due to ACE Inhibitors while edema due to CCBs will be reduced by ACE Inhibitor. However, it is important to see how we can reduce the cost of this combination therapy.

In their concluding remarks, Prof. Sajid Abaidullah said that treatment of any patient has to be individualized. Prof. Naeem Aslam stated that single pill in this combination therapy will improve patients compliance.

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