4. BP Control Rates are Suboptimal
• Despite the clear benefits of reducing BP to target level,
rate of BP control are suboptimal in most countries
• BP control rates are particularly poor in low-income
Countries
• BP control rate are <30% in several Asia-Pacific Countries
5. Get The Pressure Down!!
Awareness, Diagnosis & Best
antihypertensive which
prevent complications will
save lives !
Of Deaths
from Stroke
51%
Of Deaths
from Coronary
Heart Disease
45%
Deaths due to
HT
7.5 million
Total global
deaths
13%
http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/en/
8. Reasons for Not Achieving BP Control
Poor adherence and persistence with therapy.
Physicians’ reluctance to switch to an alternative treatment
and/or increase doses if BP remains uncontrolled.
Selected antihypertensive drug does not target the
mechanism causing the patient’s hypertension.
http://www.mayoclinic.org/diseases-conditions/high-blood-
pressure/basics/treatment/con-20019580 accessed on 9-oct-2015
10. Combination Therapy: A Practical Necessity
Required in ~ 75% of hypertensives to achieve target BP
Greater efficacy
Faster achievement of target BP
Higher response rates
May make therapy effective in broader population
Additive antihypertensive effects through complimentary pharmacologic
mechanisms
In some cases, improved side effect profile
•Gradman AH, Basile JN, Carter BL, et al. J Clin Hypertens (Greenwich).
2011;13:146–154.
11. Combination Therapy is More Effective Than
High Dose Monotherapy
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Thiazide Beta-blocker ACEI CCB All classes
Combination Double dose
Incremental
SBP
reduction
ratio
of
observed
to
expected
additive
effects
Wald DS, et al. Am J Med 2009;122:290-300
12. Higher BP Control Rates Are Achieved With Single Pill
Combinations
26
55
0
10
20
30
40
50
60
Freecombination Singlepill
12
Change
in
proportion
of
patients
achieving
BP
goals
relative
to
monotherapy
(%)
Patients receiving a single pill combination are more likely to
achieve BP goals than those receiving free combinations or
monotherapy
Gu Q, et al. Circulation 2012;126:2105-14
*p<0.05 vs monotherapy
**p<0.01 vs. monotherapy
Regional guidelines on combination therapy| March 2013
13. Single Pill Combinations are
Recommended by Guidelines
Single pill combinations (SPCs) or fixed-dose combinations have
numerous advantages over multiple drug combination therapy
Current hypertension guidelines generally recommend SPCs over
multiple drug treatment with their individual components
1. Gupta AK, et al. Hypertension 2010;55:399-407
2. Bangalore S, et al. Am J Med 2007;120:713-9
3. Dusig R. VHRM 2010;6:321-5
4. Mancia G, et al. J Hypertens 2009;27:2121-58
14. Comparison of Monotherapy and Free and Single Pill
Combinations
Monotherapy Free
combination
Single pill
combination
Convenience ✔ ✗ ✔✔a
Adherence − − ✔
Efficacy ✗ ✔ ✔
Tolerability ✗ ✔ ✔b
Flexibility ✔✔ ✔✔ ✔c
a Switching and dose titration less likely to be required than for monotherapy
b Single pill may be better tolerated as doses tend to be lower than in free combinations
c Flexibility with single pill combinations is increasing as the range of doses increases
Xinhuan Wana et al., Asian Journal of Pharmaceutical Sciences Volume 9, Issue 1, February
2014, 1–7
16. 16
Restores the podocin
and nephrin
expression, protects
the podocytes
Afferent and Efferent
arterioles (L&N
channel blocking), thus
reduced glomerular
pressure
Ameliorates urinary
albumin excretion and
decreases urinary 8-
OHdG and L-FABP
Cilnidipine has multiple approaches in reno-protection
J Hypertens. 2010 May; 28(5): 1034–1043.
Hypertens Res. 2012 Nov;35(11):1058-62. doi: 10.1038/hr.2012.96.
17. Change in pulse rate (PR) after Amlodipine and
Cilnidipine treatment compared to the
pretreatment value
Change in urinary protein/creatinine ratio during the 6-
month treatment period in the Amlodipine and
Cilnidipine group
Cilnidipine significantly reduces HR and UACR, Amlodipine increases
Zaman ZA et al. Int J Basic Clin Pharmacol. 2013 Apr;2(2):160-164
18. 18
Mega-Trial of Cilnidipine proves it reduces HR by 9.7 bpm, effective in morning hypertension
ACHIEVE-One study
These effects of cilnidipine are new features not known in conventional L‐type Ca channel
blockers
Cilnidipine reduces HR better when it is higher than 85bpm
• Generally, morning hypertension involves increased
sympathetic activity, and the renin‐angiotensin
system (RAS).
• Cilnidipine reduced MSBP and MPR even in patients
who had already been administrated β‐blockers or
RAS inhibitors (including ARBs and ACE inhibitors).
• These additive BP‐ and PR‐lowering effects of
cilnidipine may be a reflection of dual L‐and N‐type
Ca channel–blocking actions differing from
β‐adrenergic receptor blocking and RAS‐inhibiting
actions
“High-rate morning hypertension”
characterized by high MSBP and MPR.
Cilnidipine is the optimal CCB in
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034443/
21. 21
ESC/ ESH 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. 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 diuretic.
23. 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
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. 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
31. Cilacar TCGraphs
Cilacar TC Fastest Onset of Action compared to other brands, as it is quickly absorbed and
disintegrated in just 32seconds.
Cilacar TC
Telmikind Trio
Cetanil Trio
TSART Trio
32. Cilacar TCGraphs
Cilacar TC’s ingredients Mannitol, Lactose, and Microcrystalline Cellulose are imported from Germany
and France to assure Superior Quality &Therapeutic Efficacy.
Cilacar TC
Telmikind Trio
TSART Trio
Cetanil Trio
33. Cilacar TCGraphs
Cilacar TC provides Faster Therapeutic Action and Better BP Control in Uncontrolled Hypertension.
Cilacar TC
Telmikind Trio
TSART Trio
Cetanil Trio
34. 34
Summary
• Within a population of 30% affected by hypertension, 72% of the patients remain
uncontrolled in India
• The reasons for uncontrolled hypertension are varied including ignorance, mis-diagnosis /
underdiagnosis, and undertreatment, patient adherence is also a key factor
• Guidelines recommend triple combinations for uncontrolled hypertension to improve
outcomes and patient adherence
• Cilnidipine a novel CCB , well established in India in hypertension management also offers
reno-protective benefits in uncontrolled hypertensives who are at high risk for CKD
• Also, sympatholytic activities of cilnidipine make it the choice of CCB in youngsters as well for
HTN control and reduction of HR
• Hypertension is a multi-dimensional disease, which has moved beyond just control of
numbers , the major focus is on end-organ protection in the long term
• Wise choice of molecules can help patients with the best outcomes in their hypertensive
journey and improve adherence as well