Polypill strategy may not address underlying drivers of health disparities
The polypill approach to CVD prevention has demonstrated significant reduction in both BP and LDL levels but may fall short of addressing the larger underlying drivers of health disparities, a speaker reported.
“Despite advances in the prevention of cardiovascular disease, risk factor disease burdens remain unacceptably high in certain vulnerable populations,” Daniel Muñoz, MD, MPA, assistant professor of cardiovascular medicine at the Vanderbilt Translational and Clinical Cardiovascular Research Center at Vanderbilt University Medical Center, said during the presentation. “The polypill strategy may offer advantages in adherence and consequent risk reduction, but also acknowledging that the polypill is a single tactic among many required to close the disparity gap, including addressing underlying drivers in a more fundamental way. Population and precision strategies do not have to be mutually exclusive. There can be, and perhaps should be room for both as part of how we solve this challenge.”
In one trial, published in The New England Journal of Medicine, Muñoz and colleagues randomly assigned 303 residents of Mobile, Alabama, (mean age, 56 years; approximately 96% Black) to receive either a polypill or usual care. Overall, mean systolic BP was 140 mm Hg and all participants were on up to two antihypertensive medications and had no prior CVD, cancer or liver/kidney disease. In addition, 72% of polypill arm and 77% of the control arm had an annual income of less than $15,000 per year.
The individual polypill components were losartan 25 mg, hydrochlorothiazide 12.5 mg and amlodipine 2.5 mg for BP control, and atorvastatin 10 mg for cholesterol control.
Researchers noted that at 12 months, 44% of participants reported a de-escalation in their BP medication or statin therapy regime.
According to the presentation, overall BP declined in the polypill group by a mean of –7 mm Hg compared with the usual care group. The decline was more pronounced among participants who were not on antihypertensive medications at baseline.
Moreover, LDL declined in the polypill group by a mean of –11 mg/dL compared with the usual care group and the decline was more pronounced among participants who were not on statin therapy at baseline.
Investigators predicted that the 10 years risk of CVD was lower among those in the polypill group compared with patients who received usual care (mean difference, –3.1; 95% CI, –4.6 to –1.6).
“An article in the American Journal of Medicine [gave] criticism that is fair and legitimate: 'From a population standpoint, the polypill approach is akin to famine relief, which feeds the hungry in the short term, but does not tackle the underlying causes that persist. Success is only palliative and temporary.' We consider this to be a very fair and valid point and criticism and an important part of the conversation,” Muñoz said during the presentation. “An alternative way to pivot and view this would be to say on the one hand, we've got our obligation as citizens, as investigators, as clinicians to help inform how we address the underlying drivers of health disparities and on the other hand, the idea of deploying tactics like, but not limited to, the polypill to reduce health disparities.
“I would put to you, that these do not need to be at odds with each other. There may actually be a symbiosis of addressing both the art of the possible while also thinking about how socially, through policy and other efforts, we can address health disparities at a more fundamental level,” Muñoz said during his presentation. “What is the best way to reduce the burden of cardiovascular diseases? Through precision medicine or is it through a one size fits all or fits many tactics? I would say that bridging the gap likely the requires deploying the best of both.”
References:
- Cainzos-Achirica M, et al. Am J Med. 2020;doi:10.1016/j.amjmed.2020.04.017.
- Muñoz D, et al. N Engl J Med. 2020;doi:10.1056/NEJMoa1815359.
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Muñoz D. Impact of ethnicity and race in cardiometabolic health: Implications for risk assessment and management. Presented at: Cardiometabolic Health Congress; Oct. 21-24, 2020 (virtual meeting).