ORLANDO — Patients with untreated or uncontrolled hypertension reached blood pressure goals after treatment with a low-dose “triple pill,” researchers reported here.
In a study conducted in Sri Lanka and among 647 patients with data at 6 months, the triple-pill was associated with greater achievement of blood pressure target levels compared with usual care (70% versus 55%, RR 1.23, [95% CI 1.09, 1.39, P=0.0007), according to Ruth Webster, PhD, MBBS, of the George Institute for Global Health at the University of New South Wales in Sydney, and colleagues.
The triple pill was a fixed-dose combination of telmisartan (20 mg), amlodipine (2.5 mg), and chlorthalidone (12.5 mg). An option for a a double dose version at or after 6 weeks was allowed.
The maximum difference in treatment arms was observed at 6 weeks (68% versus 44%, RR 1.53, 95% CI 1.33, 1.76, the authors reported in a presentation at the American College of Cardiology annual meeting.
“Based on our findings, we conclude that this new method of using blood pressure-lowering drugs was more effective and just as safe as current approaches,” Webster said.
She said that high blood pressure is undertreated worldwide, with rates ranging from 20% of patients untreated or undertreated in some resource limited countries to around 50% of the population in countries such as the U.S.
In the TRIUMPH trial, 700 participants were randomized. At baseline, the mean age was 56, 58% were women, 32% had diabetes or chronic kidney disease, 48% were untreated and the mean blood pressure was 154/90 mmHg.
At 6 months, 83% of the triple-pill group were still receiving the study drug, while a third of the usual care group were receiving at least two blood pressure lowering drugs.
The authors also reported that there was no significant difference in adverse events between randomized groups (38.7% versus 34.7%, P=0.31). Also, there was no significant heterogeneity in efficacy by baseline use of blood pressure lowering drugs.
“The triple pill approach is an opportunity to ‘leap frog’ over traditional approaches to care, and adopt an innovative approach that has been shown to be effective,” Webster stated. “A control rate of 70% would be a considerable improvement even in high-income settings. Most hypertension guidelines in these countries do not recommend combination blood pressure-lowering therapy for initial treatment in all people. Our findings should prompt reconsideration of recommendations around the use of combination therapy.”
Click here for video comments from study authors and discussants at ACC 2018.
Karol Watson, MD, of the David Geffen School of Medicine at the University of California Los Angeles, agreed, stating that “This is something we have know about for years, but we never do. We are told to take one medication as far as we can, and then think about using another. We have decades of evidence that shows this doesn’t really improve efficacy.”
“Now we see that we can start with three drugs, and they don’t even have to be that high. Low-dose combinations have synergistic effects that improve blood pressure control,” she added.
Webster disclosed no relevant relationships with industry.
Watson disclosed relevant relationships with Amgen, AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo, GlaxoSmithKline, and Merck.