By Lilian Anekwe
Exclusive: The management of hypertension is set to be radically shaken up, with sequential use of antihypertensives likely to be thrown out in favour of early use of combination drugs, Pulse can reveal.
Leading cardiologists developing version three of the Joint British Societies’ guidance on cardiovascular disease, due out in October, say combination antihypertensives are set to be recommended ‘much earlier in the treatment algorithm’.
The use of combination therapies – including triple combinations currently in late-stage clinical trials – would be designed to promote rapid and aggressive blood-pressure control, and would be a major change to current practice.
GP prescribing figures from Cegedim Strategic Data show combinations accounted for only 0.2% of antihypertensive prescribing in the past two years.
Professor Peter Sever, professor of clinical pharmacology at Imperial College London and member of the guideline working party for the British Hypertension Society – part of the JBS – said the JBS3 committee was considering promoting use of combination therapies.
‘Blood pressure is often not controlled and most patients need a combination of drugs. The advocation of combination treatment much earlier in the treatment algorithm – at, say, stage two hypertension in patients with systolic blood pressure above 160mmHg – would go a long way to address that.
‘From the ASCOT trial, combinations of calcium-channel blockers and ACE inhibitors or ARBs will be the preferred option. A lot of people, including NICE, have accepted ß-blockers have had their day.’
The results of several trials of triple combination antihypertensives – due in the next few months – could provide evidence for the JBS3 committee to rewrite its guidance.
Professor Sever said the JBS3 guidance would also insist GPs take early treatment of hypertension ‘more seriously’, adding: ‘We will re-emphasise the importance of controlling blood pressure quickly.’
Professor Morris Brown, professor of medicine at the University of Cambridge and another member of the BHS guidelines group, confirmed combination therapies ‘will certainly be discussed heavily’ – not only by JBS but also by NICE.
‘NICE will look at the question of whether combinations should be used first off. There are trials due in the next few months looking at that.’
But Professor Brown, who chaired the group who wrote the JBS2 guidance, said any guidance encouraging aggressive blood-pressure treatment might be relaxed for some patients, after an analysis of the ACCORD trial showed there was no significant benefit of intensive blood-pressure control in patients with type 2 diabetes.
Dr Ivan Bennett, a GPSI in cardiology in Manchester, said: ‘There is evidence combination treatment may improve control. It does restrict tinkering with the doses of individual drugs, but it could reduce the tablets people take.’
JBS set to push use of BP drug combinations