Advances in treatment strategies of hypertension in elderly subjects: Very low dose combination in first line

Hypertension significantly increases with age, and it represents an important cause of morbidity and mortality in older population. In the elderly, hypertension assumes peculiar clinical aspects related to the complex condition of progressive reduction of morphological and functional performance of all organs and apparatuses as well as to the presence of comorbidity and chronicity contributing to definition of the concept of age-related vulnerability and frailty. Although several large studies have demonstrated that drug treatment may decrease morbidity and mortality accompanying elevated blood pressure in the elderly, the lack of clinical trials including the oldest old and the "frail elderly", does not allow the clinical practitioner to apply the results of the evidence-based medicine to these patients. The current tendency in the pharmacological management of elderly hypertensive patients is to avoid an aggressive approach, because of the presence of several clinical conditions, which can induce negative synergisms with drug assumptions. The utilization of fixed low dose combination therapy, as first line treatment of hypertension has been demonstrated efficacious and safe in older patients. In particular, several studies have been developed on the efficacy of the very low dose combination, perindopril 2 mg/indapamide 0.625 mg, in monotherapy, in the treatment of elderly hypertensive patients. This association has been proven to induce a normalization rate in 96.2 % of patients treated, and an 80 % of responders between patients with isolated systolic hypertension. Similar results have been obtained in a study population of hypertensive old-old patients (mean age: 82.3 years) treated with perindopril plus indapamide, at very low doses, over a period of 3 months. In this study, combination therapy was able to reduce significantly the systolic and diastolic blood pressure, by 29.7 % and 18.7 %, respectively, with a high percentage of normalization and responders. A significant advantage of the fixed very low dose combination therapy is represented by its high clinical tolerability both in young and elderly hypertensive patients. The frequency of adverse effects with combination therapy, perindopril plus indapamide, results to be comparable to placebo. The encouraging results of the first experients, in the treatment of hypertension in the elderly with fixed low dose combination, justify the development of further studies on largest study population, in order to definitively establish the role of this pharmacological approach in older hypertensives.