In this issue of Hot Topics in Hypertension, Dr. Waeber presents an erudite and thorough review of the need for combination treatment in hypertension. Over the past three decades, practicing physicians have had access to new, effective and well tolerated antihypertensive agents, but nonetheless, the rates of blood pressure control have not improved. In clinical trials, regardless of the drugs or doses used, antihypertensive monotherapy succeeds in bringing blood pressure to the target of <140/90 mmHg in only 50% of patients at best. Judicious addition of other drugs that have a different mode of action than the initial drug can greatly increase the rates of blood pressure control. However, the prevailing habit of patiently searching for the "right" combination for each individual patient is fraught with difficulties. One of the major but unreported consequences of drug up-titration is patient disappointment with the slow progress, which results in loss of trust in the physician, apathy and eventually lack of compliance with the drug regimen. Physicians, on the other hand, are concerned that rapid addition of other drugs may cause side effects.
In this well documented scholarly review of monotherapy with hydrochlorothiazide, valsartan or amlodipine, and combination pills, valsartan/hydrochlorothiazide and valsartan/amlodipine, the author shows that fixed combination pills are safe, well tolerated and effective. He also provides practical guidance on when to use or avoid a particular type of combination pill.
The need for combination therapy is clearly present; the blood pressure in many of our patients is not well controlled, and combination pills provide an excellent tool for achieving the desired blood pressure target.
The triple combination pill of valsartan/hydrochlorothiazide/amlodipine has also become available and the author wisely suggests reserving its use for patients resistant to double combination pills.