Off to a Bad Start With Fixed Combinations
The authors cite the new ESC guideline recommendations of directly starting a fixed combination of antihypertensive agents for persons with significantly high blood pressure (or those at an increased risk for it) (1, 2). However, there are no studies to date that compare cardiovascular events in monotherapy versus combination therapy (2). Instead, the rational given are the high rates (25%–65%) of poor adherence to therapies with multiple antihypertensive drugs; however, these rates were reported for patients with treatment resistance or in tertiary care (3, 4) and are therefore not transferable to primary care. From the point of view of primary care, controllability of the individual drugs in the phase of blood pressure adjustment makes sense and allows the adverse reactions specific for each drug to be more easily recognizable. Many fixed combinations are significantly more expensive than single drugs. This is particularly true for the combinations of ACE inhibitors and AT1 blockers with calcium antagonists shown in Figure 5 in the article. When therapy was started in the hospital, diuretic combinations are often overdosed afterwards in the home environment because of the delayed-onset effect. Starting a fixed combination in the inpatient phase requires the primary care physician to carry out a time-consuming adjustment of medication after discharge.
Dr. med. Kai Florian Mehrländer
Gemeinschaftspraxis Dres. Mehrländer & Schwartz, Barmstedt, Germany
Conflict of interest statement
The author declares that no conflict of interest exists.
|1.||Jordan J, Kurschat C, Reuter H: Arterial hypertension—diagnosis and treatment. Dtsch Arztebl Int 2018; 115: 557–68 VOLLTEXT|
|2.||Williams B, Mancia G, Spiering W, et al.: 2018 ESC/ESH guidelines on hypertension. J Hypertens 2018. https://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehy339/5079119 (last accessed on 1 September 2018).|
|3.||Gupta P, Patel P, Strauch B, Lai FY, et al.: Biochemical screening for nonadherence is associated with blood pressure reduction and improvement in adherence. Hypertension 2017; 70: 1042–8 CrossRef MEDLINE PubMed Central|
|4.||Webster R, Salam A, de Silva A et al. Fixed low-dose triple combination antihypertensive medication vs usual care for blood pressure control in patients with mild to moderate hypertension in Sri Lanka. A randomized clinical trial JAMA. 2018; 320: 566–79 CrossRef|