A step in the global effort to control hypertension: Fixed dose combination antihypertensive drugs

Abstract

Increased blood pressure is the single most important modifiable risk for death and a major driver of non-communicable disease (NCD) globally. 1 Controlling hypertension is perhaps the single most effective and feasible clinical mechanism to reduce NCD death and disability by reducing cardiovascular, cerebrovascular, and renal diseases. Hence, hypertension has been viewed as a major entry point for patients to the health care system for the prevention of NCD and is a major global target of the World Health Assembly, World Health Organization, and the philanthropic organization, Resolve To Save Lives. 2-4 Through the HEARTS program, developed by the World Health Organization in partnership with multiple other organizations including the World Hypertension League, global best practices for hypertension control have been established. 4 HEARTS outlines critical health system changes that are required for a feasible, effective global public health approach to hypertension control. Needed health system changes include a reliable and affordable supply of a high quality core set of antihypertensive medications including fixed dose combinations (FDCs), easily accessible patient-centered team-based care, accurate and systematic evaluation of blood pressure at all clinic visits, community based screening for hypertension that is closely linked to the health system and ensures the majority of people with hypertension are identified, use of a simple directive diagnostic and therapeutic treatment protocol, use of a hypertension registry with performance reporting, and regular (3-5 year) population blood pressure surveys. The vast majority of 1.13-1.4 billion people with hypertension should be managed by primary care close to where they live and work. 5,6 The effort to control hypertension is aligned with another major effort to empower and build universal primary care and its capacity globally. 7 Ultimately, global hypertension control requires a vast expansion of primary care and achieving hypertension control needs to be a major priority for primary care. Unfortunately, experience indicates that implementing specific global best clinical practices in hypertension are often opposed by hypertension specialists. Some specialists may be unaware of the evidence supporting the best practices, the need for a public health approach vs individualized care or of the difficulties in implementing Abstract Several fixed dose combinations (FDCs) of antihypertensive drugs have recently been added to the World Health Organization model list of essential medications. FDCs have advantages in the management of hypertension compared to single drug tablets including improved adherence, greater blood pressure lowering and are associated with reduced cardiovascular complications. FDCs can also reduce ethnic, and age-related variation in blood pressure lowering and have similar or reduced adverse effects relative to single-drug therapy. Best hypertension control practices from the World Health Organization HEARTS program advocates the use of FDC in...

Effects of Simplified Antihypertensive Treatment Algorithm on Hypertension Management and Hypertension-Related Death in Resource-Constricted Primary Care Setting between 1997 and 2017

“…In our sample, antihypertensive takers were older (57.1 vs. 48.0 years, P < 0.001) and had larger BMI (28.2 vs. 25.8 kg/m 2 , P < 0.001), compared with the untreated (data not given). In addition, >70% hypertensives need ≥2 agents to reach target BP [38], whereas almost 90% hypertensives from Xinjiang were taking single agent in 2012-2015, based on our another survey [39], which may be even more worse decades ago.…”

Standardized treatment to improve hypertension control in primary health care: The HEARTS in the Americas Initiative

“…This initiative also supports HEARTS countries in adopting new treatment protocols. A single pill, FDC, has substantial advantages for patients and healthcare programs including most (70%‐80% of individuals) will need two agents eventually; two agents selected from complementary classes yields greater blood pressure (BP) reduction efficacy, which allows the usage of lower doses of each agent and a reduction in side effects of either agent; reduces clinical/therapeutic inertia; improves adherence; allows simpler dose schedules; decreases pill burden; lowers the BP equally among diverse demographic groups (sex, age, race, and ethnicity); simplifies logistics leading to fewer medication stock‐outs; provides greater ease of task sharing, training, and supervision; and efficient for supply chain management and procurement at scale 18,20,22‐24 …”

“…At the healthcare system level, factors, such as a lack of clinic and provider access, poor availability of quality, affordable and reliable medications, the inability to sustain recognition and treatment programs once initiated, and budgetary constraints, all prevent the widespread use of antihypertensive medications, which contributes to poor treatment and control rates 23 . The prescribing practice is driven by many considerations including accessibility, ease of use, cost, and tolerance of therapy.…”