Prescribing patterns in hypertension: the emerging role of fixed-dose combinations for attaining BP goals in hypertensive patients

Background. The attainment of clinical blood pressure (BP) goals can markedly reduce cardiovascular morbidity and mortality, yet approximately two-thirds of treated hypertensive patients in the United States have uncontrolled BP. Consequently, more aggressive management of hypertension, frequently involving combination therapy (e.g., fixed-dose combination [FDC] therapy), is needed to achieve the recommended BP goals of <140/90 mmHg for most patients, and <130/80 mmHg for high-risk patients. Scope: This article, based on data from an extensive Medline search ('hypertension' AND 'prescribe', 'prescribing' OR 'prescription', date range: 1995-2007), focuses on prescribing patterns for anti hypertensive medication, and on the emerging role of combination therapy, specifically FDC therapy, in treating hypertensive patients to target BP levels. Findings: Although the use of anti hypertensive combination therapy has increased substantially in US adults over the last 20 years, such therapy remains considerably underutilized. Numerous studies have shown that combination therapies, including FDCs, can markedly reduce BP and adverse events relative to monotherapies, and this paper overviews data for various combination therapies: angiotensin-receptor blocker (ARB) + diuretic; angiotensin-converting enzyme (ACE) inhibitor + diuretic; calcium-channel blocker (CCB) + ACE inhibitor; and CCB + ARB. Specifically, fixed-dose CCB/ARB combinations of ani pine with losartan, valsartan, or olmesartan medoxomil have recently been developed, and combination therapy schedules of amlodipine plus one of these ARBs have shown greater BP-lowering efficacy compared with the constituent monotherapies. Furthermore, in two large studies in a total of >3000 patients, CCB + ARB combination therapy was associated with significantly lower incidences of headache and peripheral edema than CCB monotherapy. Conclusion: Guidelines for hypertension management clearly support the greater use of multidrug therapy, especially in high-risk patients. FDCs (e.g., various emerging CCB/ARB combinations) are a valuable option for such high-risk patients, as these combinations offer the potential to reduce adverse events, increase compliance, lower treatment costs, and improve BP goal-attainment rates.