The document discusses the rationale and history of using combination therapy to treat hypertension. It notes that combination therapy has been used since the 1950s and studies in the 1960s showed improved blood pressure control and reduced morbidity. Guidelines now recommend initial combination therapy using single pill combinations over stepwise monotherapy due to greater effectiveness in reducing blood pressure and heart disease risk. For patients still uncontrolled on dual therapy, guidelines recommend adding a third drug, often in a single pill combination, to help achieve target blood pressure goals.
Combination Therapy In Hypertension - Dr Vivek Baliga PresentationDr Vivek Baliga
Dr Vivek Baliga of Baliga Diagnostics, Bangalore, discusses the common combination therapies used in the management of hypertension in clinical practice.
Combination Therapy In Hypertension - Dr Vivek Baliga PresentationDr Vivek Baliga
Dr Vivek Baliga of Baliga Diagnostics, Bangalore, discusses the common combination therapies used in the management of hypertension in clinical practice.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
ARBs (Angiotensin receptor blockers) are the most widely used anti hypertensive throughout the world. A solid knowledge related to ARB will make our practice more patients friendly & benefit will be maximum.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
ARBs (Angiotensin receptor blockers) are the most widely used anti hypertensive throughout the world. A solid knowledge related to ARB will make our practice more patients friendly & benefit will be maximum.
Recent Advancements in the treatment of Hypertension.Akshata Darandale
Uncontrolled blood pressure had become most common cause of death accounting for more than 7 million deaths per year worldwide. Despite the availability of potent lifestyle and pharmacologic approaches, rates of control of blood pressure are unsatisfactory and additional strategies to curb the burden of hypertension are warranted. Several novel pharmacological and device-based approaches have recently been tested and may prove helpful to achieve better blood pressure control rates and thereby improve cardiovascular outcomes in patients with hypertension.
In this overview, we draw inspiration from the article titled "Managing Hypertension in Primary Care“, published in the Canadian Family Physician journal (Vol 65: October 2019).
The article, edited by Khrystine Waked PharmD, Jeff Nagge PharmD, and Kelly Grindrod PharmD MSc,.
It provides valuable insights and evidence-based approaches to tackle Hypertension Management In Primary Care.
By incorporating the recommendations discussed in this article, we can enhance our ability to manage hypertension and ultimately improving patient outcomes and quality of life.
The Health Innovation Network Polypharmacy Programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications.
Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely.
To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Assessing the outcomes of structured medication reviews, can be viewed here.
For more information about the polypharmacy programme, please visit https://thehealthinnovationnetwork.co.uk/programmes/medicines/polypharmacy/
provide recommendations for alternative drug treatments to address.docxsimonlbentley59018
provide recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples
Week 9 Initial Post- Mel Mal,
COLLAPSE
Top of Form
This case study presents a particularly hard case to untangle. The 46-year-old women is exhibiting the night sweats, hot-flushing, and genitourinary symptoms common in menopause. The patient is still getting a regular period, so these symptoms are most likely pre-menopausal, as periods stop in true menopause. In a patient with no familial history increasing the patient’s risk for breast cancer, an estrogen or combination estrogen/progestin therapy would most likely be initiated (Rosenthal et al. 2021). This therapy would likely reduce the uncomfortable symptoms, however in a patient with a family history of breast cancer, the therapy can increase the likelihood of breast cancer occurrence.
Luciano et al., found that both estrogen therapies and combined estrogen/progestin therapies increased the risk for breast cancer (2020). It is important to notice that this study notes that the risks for patients who take the therapy on a short-term basis are at a slightly lower risk, however this patient is young at 46 years old and would possibly need a long-term medication solution.
On the opposite side, Carr summarizes the North American Menopause society’s 2022 updated guidelines on hormonal replacement therapy and explains that a patient with menopausal symptoms can take combined hormone therapy until at least the mean age of menopause (53) without any significant increase in breast cancer (2022). With the newest recommendations, I would recommend that the patient start a combined estrogen and progestin hormone therapy for reduction in symptoms. With this recommendation is the caveat that the patient will need regular visits to re-evaluate the need for the therapy with hopeful cessation of treatment within three to five years to keep any increase in breast cancer risk to a minimum.
The lowest dose medication should be used for the shortest time period in order to reduce comorbidity risk so this patient recommendation will be to start Prempro 0.3mg/1.5mg daily and then reevaluate for effectiveness and need to increase dosage (Rosenthal et al., 2021).
The patient also needs adjustments in her hypertension medication. The patient is currently on Norvasc 10mg daily, and HCTZ 25mg daily. This therapy is within guidelines because she is on Norvasc, a calcium-channel blocker, and Hydrochlorothiazide, a thiazide diuretic, are being used to potentiate each other’s effects. In cases where a thiazide diuretic is ineffective in controlling HTN, a loop diuretic may be added. In this patient, we will recommend adding Furosemide to hopefully control the hypertension. This dosage will start low, at 20mg daily, (taken in the morning to decrease nocturia), with regular home blood pressure checks as well as in office re-evaluation to determine how effective the medication and dosage are (.
The actual prevalence of RH may be lower than what is
perceived in the literature when triple-A (accuracy of BP
measurement, adherence of medications, and adequacy
of anti-HTN medications) are ensured. It is important to
emphasize that the sea of RH starts when the shore of secondary
HTN is over and the island of RfH is still uncharted. RfH is
emerging as a novel phenotype, and growing evidence suggest
that these patients have sympathetic hyperactivity. However,
the role of beta-blockers and interventions such as RDN and
baroreceptor activation techniques is yet to be studied.
Similar to Combination therapy in hypertension (20)
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?
Combination therapy in hypertension
1. COMBINATION THERAPY
IN THE MANAGEMENT OF
HYPERTENSION
NOWADAYS: WHEN AND
HOW?
DR PRADIP MATE
SR MEDICAL MANAGER
MEDICAL SERVICES
USV PVT LTD
MUMBAI
2. • The concept of initial
combination therapy is not new
because one of the first large
clinical trials published in the late
1960s, the Veteran Affairs
Cooperative Study, showed
reduced morbidity with improved
BP control using triple therapy
combinations.
3. HISTORY OF COMBINATION THERAPY
The use of combination
therapies started in the
1950s, when pills
containing reserpine
were introduced.
Several other formulations in the
1960s and 1970s that contained
thiazide diuretics, including the
triple combination pill of
hydralazine and
hydrochlorothiazide and
reserpine, as well as in
combination with potassium-
sparing diuretics, beta-blockers,
and clonidine.
In the 1980s, thiazides
were combined with
angiotensin-converting
enzyme (ACE) inhibitors
In 1990s, a combination
of an ACE inhibitor and
calcium channel blocker
(CCB) was approved
Hala Yamout and George L. Bakris. Use of Combination Therapies. HYPERTENSION A Companion to Braunwald’s Heart Disease. Third Edition . 2018
4.
5. RATIONALE FOR INITIAL COMBINATION
THERAPY : GUIDELINE INERTIA
• Although combination BP lowering therapy was available and proven to reduce BP and
mortality in clinical trials, the control of BP with stepwise management was advocated
by early guidelines
• The first report favoring combination therapy as an initial approach was seen in 1997
by the JNC VI panel.
• Since this report, it is clear that initial use of single pill combination therapy is superior
to a stepwise approach in controlling hypertension, with 12% more patients at their
target BP.
Hala Yamout and George L. Bakris. Use of Combination Therapies. HYPERTENSION A Companion to Braunwald’s Heart Disease. Third Edition . 2018
6. RATIONALE FOR INITIAL COMBINATION
THERAPY : MULTIFACTORIAL CAUSES OF BP
• Multiple systems that regulate BP ; sympathetic nervous system (SNS), renin-angiotensin
system (RAS), and volume modulators from the kidney and heart like natriuretic peptides.
• It is difficult to determine with certainty which system is dominant in a particular patient
• Use of different classes of medications will increase the chance of controlling BP faster and
more effectively.
• An increase dose of a single agent is less likely to achieve BP control than adding lower doses
of a second agent.
Hala Yamout and George L. Bakris. Use of Combination Therapies. HYPERTENSION A Companion to Braunwald’s Heart Disease. Third Edition . 2018
7. RATIONALE FOR INITIAL
COMBINATION
THERAPY : EFFECTIVE BP CONTROL
• Addition of an antihypertensive
agent from a different class is five
times more effective in improving
BP control than doubling the dose
of a single drug.
• Improvement in BP control occurs
when even half the dose of the
individual drugs are used in a
combination pill compared with full
doses of each as monotherapy
Comparison of observed versus
expected effects of a single pill
combination versus doubling the dose of
an antihypertensive medication.
Hala Yamout and George L. Bakris. Use of Combination Therapies. HYPERTENSION A Companion to Braunwald’s Heart Disease. Third Edition . 2018
8. RATIONALE FOR INITIAL COMBINATION
THERAPY : COUNTER REGULATORY MECHANISM
Diuretics used alone can
result in relative volume
depletion and activate
the RAS and to a lesser
extent the SNS.
The use of agents that
block these systems,
such as ACE inhibitors or
beta-blockers, counteract
the body’s response to
diuretics and are
complementary to
diuretic action to low BP.
To offset the
body’s counter-
regulatory
mechanisms to a
particular agent
Hala Yamout and George L. Bakris. Use of Combination Therapies. HYPERTENSION A Companion to Braunwald’s Heart Disease. Third Edition . 2018
9. CV RISK REDUCTION
Every 20 mmHg increase in systolic blood
pressure, there is an approximate doubling
of cardiovascular (CV) risk, by use of
combination therapy there is better
achievement of target BP goals thereby
reduction in CV risk.
Monotherapy especially with beta blockers
results in variability in visit to visit BP
recordings which is a strong predictor of
both stroke and myocardial infarction this
effect is reduced with combination drug
therapy
AU Mahajan, Zohaib Shaikh. Combination Drug Therapy in Hypertension . Medicine update . 2017
10. Illustration of various drug class combinations to lower
blood pressure and CV event
Solid black lines
demonstrate
additive effects
on blood
pressure (BP)
lowering;
Orange lines
demonstrate
outcome
based
reduction in
either
cardiovascular
events or
kidney disease
progression
Hala Yamout and George L. Bakris. Use of Combination Therapies. HYPERTENSION A Companion to Braunwald’s Heart Disease. Third Edition . 2018
11. IMPROVE PATIENT
ADHERENCE
• Even when the same two
drugs are given as
individual pills, adherence
rates with combination
therapy are significantly
higher and can reduce
nonadherence by up to
24%
Adherence with single pill combinations
compared with free-drug combinations
Hala Yamout and George L. Bakris. Use of Combination Therapies. HYPERTENSION A Companion to Braunwald’s Heart Disease. Third Edition . 2018
12. Forest plot for medication persistence.
Meta- analysis confirmed that FDC
therapy, compared with free-
equivalent combinations, was
associated with better medication
adherence or persistence for patients
with hypertension.
It can be reasonable for physicians,
to facilitate the use of FDCs for
patients who need to take two or
more antihypertensive drugs
14. AMERICAN SOCIETY
OF HYPERTENSION
EVIDENCED-
BASED FIXED-DOSE
ANTIHYPERTENSIVE
COMBINATIONS
Hala Yamout and George L. Bakris. Use of Combination Therapies. HYPERTENSION A Companion to Braunwald’s Heart Disease. Third Edition . 2018
15. Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press
Hypertension drug treatment strategies
Increasing dose of initial monotherapy (side
effects/ineffective)
Substitution with another monotherapy ( time consuming/low
adherence/ineffective)
Stepped-case approach,i.e.monotherapy with sequential addition of
other drugs (therapeutic inertia)
16. Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press
Rationale for initial two-drug combination therapy
in most patients
Greater BP reduction vs monotherapy
Reduced heterogeneity of the BP response
No /Small increase in hypotensive episodes
More frequent BP control after 1 year
- Better adherence to treatment
- Reduced therapeutic inertia
Reduced CV events
17. • Faster reduction of BP
• Greater possibility of achieving target BP
• Neutralization of the counterregulatory pathway
activated by monotherapies
• Improved tolerability
• Decreased side effects than up- titrating single
agents
Cardiac Failure Review 2017;3(1):40–5
Single Pill Combinations
18. Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press
The recommended treatment
strategy (evidence-based) to improve BP control
Initial combination treatment, especially useful in the
context of lower BP targets
Single-pill-based combination therapy, to improve
adherence to treatment
To be used in most patients
Initial monotherapy reserved to BP in the high-normal
range/very old patients/ frail older patients)
21. ESC/ ESH 2018
HYPERTENSION GUIDELINE
RECOMMENDS DUAL
COMBINATION THERAPY AS
A INITIAL THERAPY
First look at the new 2018 European Guidelines for the treatment ofhigh blood pressure. 2018 ESC and ESH joint guidelines for
themanagement of arterial hypertension. Available from URL:http://www.eshonline.org/esh-annual-meeting/
22. TRIPLE DRUG COMBINATION
• About 24% to 32% of patients with HTN will require more than two
drugs to achieve their BP target.
• A rational combination in this setting would be an RAAS inhibitor, a
CCB, and a diuretic6.
23. Single-pill triple combinations of different classes of drugs with complementary
mechanisms of action help to treat patients to goal with improved efficacy and better
adherence to treatment
Journal of Human Hypertension (2017) 31, 501–510;
Triple drug fixed dose combination of Telmisartan, Amlodipine and hydrochlorothiazide
was found to be effective and safe option for the optimal management of hypertension.
24. TRIPLE DRUG COMBINATION
• Triple fixed-dose drug combinations should be reserved only for patients with uncontrolled
BP with 2 agents, poor adherence in complex therapeutic regimens or on inappropriate free-
drug combinations.
• Triple therapy may help overcome clinical inertia by prescribing more potent antihypertensive
formulations in one pill.
• Beyond the choice between different triple fixed-dose combinations it is important to
evaluate at shortterm whether BP is controlled within target and whether the administered
fixed-dose treatment is associated with good compliance
Curr Vasc Pharmacol. 2017;16(1):61-65.
26. How to build up appropriate triple drug combinations.
Curr Vasc Pharmacol. 2017;16(1):61-65.
27. ESC/ ESH 2018 HYPERTENSION
GUIDELINE RECOMMENDS
TRIPLE COMBINATION THERAPY
IF BP NOT CONTROLLED BY
DUAL THERAPY
First look at the new 2018 European Guidelines for the treatment ofhigh blood pressure. 2018 ESC and ESH joint guidelines for
themanagement of arterial hypertension. Available from URL:http://www.eshonline.org/esh-annual-meeting/
28. CHANGING TRENDS IN PHARMACOTHERAPY FOR
HYPERTENSION IN INDIA
47
53
0
10
20
30
40
50
60
70
Mono Combo
Malhotra et al. Eur J Clin Pharm.
2001;57:535
N=1076
Sreedharan et al. Int J Clin Pharm Ther.
2011;49:277
49
51
0
10
20
30
40
50
60
70
Mono Combo
N=2100
27
73
0
10
20
30
40
50
60
70
Mono Combo
Gupta R, et al.
2018. Unpublished.
N=3073