Low-Dose Quadruple Therapy for Hypertension

Hypertension can be easily detected at the community pharmacy or primary health-care level.  In addition, it is relatively cost-effective to treat and control.  The estimated number of adults with hypertension is now 1.2 billion people.¹   World-wide data (200 countries) from 1990-2019 in persons aged 36-79, from population-based studies of blood pressure measurement and treatment (104 million participants) found improvements in detection, treatment and control of hypertension vary widely.¹ Interestingly, middle-income countries (ie, Costa Rica, Taiwan, Brazil, Chile, Turkey, and Iran) outperformed some high-income countries (ie, Europe and US). Overall, 59% of women and 49% of men with hypertension reported a previous diagnosis of hypertension in 2019, with 23% and 38% treated.  Unfortunately, only 23% and 18%, respectively were controlled.   

So what can be done to improve the treatment and control of hypertension worldwide?  Another recent study from the University of Sydney, Australia in 300 persons randomly assigned a quadpill (irbesartan 37.5mg, amlodipine 1.25mg, indapamide 0.625mg, and bisoprolol 2.5mg) or an indistinguishable monotherapy control (irbesartan 150mg) daily for 12 weeks found that the fixed-dose quadpill maintained greater blood pressure lowering (-6.9 mmHg SBP [95% CI:4.9-3.9, P<0.0001]).  Blood pressure control rates were 76% in the quadpill group versus 58% in the control group ([RR]: 1.30, 95% CI:1,15-1.47, P<0.001). There was no difference in adverse events or treatment-related withdrawals.

Given the increasing prevalence, poor treatment and control of hypertension around the world, including well-developed nations, this data is welcome. This data brings a new paradigm to the treatment and potential control of millions of persons around the world including the United States.  Do not be surprised if a quadpill becomes available in the US soon for hypertension.

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References:

1. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. Lancet. 2021;398(10304):957-980. doi:10.1016/S0140-6736(21)01330-1 
2. Chow CK, Atkins ER, Hillis GS, et al. Initial treatment with a single pill containing quadruple combination of quarter doses of blood pressure medicines versus standard dose monotherapy in patients with hypertension (QUARTET): a phase 3, randomised, double-blind, active-controlled trial. Lancet. 2021;398(10305):1043-1052. doi:10.1016/S0140-6736(21)01922-X