Polypill for blood pressure lowering may improve adherence and reduce mortality
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Key takeaways:
- A polypill approach to renin-angiotensin system inhibition may improve adherence in patients with hypertension.
- Polypills were associated with fewer adverse cardiovascular events vs. multiple pills.
A renin-angiotensin system combination polypill to treat high BP was associated with improved adherence and lower all-cause mortality and CV event rates vs. taking multiple pills, researchers reported.
Across four different renin-angiotensin system (RAS) inhibitor combination polypills, researchers observed fewer CV events including MI, CAD, HF, stroke and transient ischemic attack, according to the results of the START study published in Hypertension.
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“The main takeaway from the START study is that a single pill combining several antihypertensives is in favor to identical loose combinations not only regarding improved persistence, but also leads to better CV outcomes and reduced all-cause mortality,” Olaf Randerath, head of medicine at Apontis Pharma, and Roland Erich Schmieder, professor of internal medicine in the department of nephrology and hypertension, head of the Clinical Research Centre and vice chair of the department of nephrology and hypertension at University Hospital Erlangen, Germany, told Healio.
For this retrospective analysis of German AOK PLUS claims data, Schmieder and colleagues included 57,998 patients who received one of four RAS inhibitor combinations to treat hypertension between 2012 and 2018.
Participants received the following combinations as single polypills or separate multiple pills: 10,801 patients received valsartan/amlodipine (Exforge, Novartis); 1,026 received candesartan/amlodipine; 15,349 received ramipril/amlodipine; and 1,823 received amlodipine/valsartan/hydrochlorothiazide (Exforge HCT, Novartis).
The age range within this cohort was 65 to 72 years, and included slightly more women than men. The CHA2DS2‐VASc score ranged between 3 and 4 and median follow-up was 1.39 years.
Benefits of a polypill vs. multiple pills
The researchers observed a lower rate of all-cause mortality among individuals prescribed a polypill compared with multiple pills:
- valsartan/amlodipine polypill vs. multiple pills (incidence rate ratio [IRR] = 0.761; 95% CI, 0.683-0.848; P < .001);
- candesartan/amlodipine polypill vs. multiple pills (IRR = 0.538; 95% CI, 0.284-0.98; P = .031);
- ramipril/amlodipine polypill vs. multiple pills (IRR = 0.526; 95% CI, 0.463-0.596; P < .001); and
- amlodipine/valsartan/hydrochlorothiazide vs. multiple pills (IRR = 0.515; 95% CI, 0.375-0.709; P < .001).
Schmieder and colleagues observed lower rates of MI, CAD, HF, stroke and TIA across most polypills compared with multiple-pill approaches, with nonsignificant trends toward lower rates of MI observed among valsartan/amlodipine, candesartan/amlodipine and amlodipine/valsartan/hydrochlorothiazide cohorts and nonsignificant trends toward lower rates of stroke and TIA within the candesartan/amlodipine group.
Moreover, 1-year adherence to the multiple-pill approach was between 20% and 49% lower compared with the polypill approach across RAS inhibitor combinations.
‘Wider use of single pills might be missing awareness’
“The main barrier hindering a wider use of single pills might be missing awareness and knowledge how profoundly adherence impacts CV prognosis in patients requiring long-term treatment with several antihypertensives in the physician’s daily practice,” Randerath and Schmieder told Healio. “One solution could be the development of an algorithm when to switch from multi-pill to single-pill strategy in daily practice at the point of prescription. This is easily possible when patients join the practitioner’s office to get a new prescription for their antihypertensive medication. In some countries, practice management software is standard of daily business. These systems easily could help to identify patients on loose combinations that are suited for an available single pill solution.
“In addition, more combinations need to be developed as single pill in different dosages by pharmaceutical companies,” they said. “However, the first and most important step is that physicians become aware what benefit a single pill could provide for their patients. This needs to be more implemented into certified medical education.”
For more information:
Olaf Randerath can be reached at olaf.randerath@apontis-pharma.de.
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