Optimizing blood pressure control through the use of fixed combinations

The majority of hypertensive patients need ≥2 antihypertensive agents to reach goal blood pressure. As an estimate, one-third of unselected hypertensive patients may be successfully treated with monotherapy, one-third may require 2 and the remaining one-third of patients will need ≥3 antihypertensive agents for effective blood pressure control. However, doctors are often hesitant to expand therapy in treated patients whose blood pressure is not lowered to goal (therapeutic inertia). Multiple-drug therapy in the majority of hypertensive patients may also represent one of several factors responsible for the low rates of adherence with chronic antihypertensive treatment. As a consequence, both US and European guidelines recommend single pill combinations to lower the number of pills needed in order to increase medication adherence and, possibly, reduce therapeutic inertia. For 2 drug combinations, the recently revised European (ESC/ESH) guidelines recommend the following options: diuretic plus either calcium channel blocker (CCB) or renin–angiotensin system (RAS) blocker (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker) or CCB plus RAS-blocker. In the absence of substantial evidence, neither JNC-7 (from 2003) nor the European guidelines from 2007 give any meaningful advice on triple combination treatment. It is therefore of interest that the 2009 reappraisal of the European guidelines gives preference to the combination of a RAS blocker and a CCB plus a diuretic. On the background of the substantial number of patients requiring ≥3 drugs for blood pressure control, the recent approval of a single-pill 3-drug combination composed in accordance with the above mentioned ESC/ESH recommendations should be appreciated.