Antihypertensive combination treatments better than monotherapy for lowering BP

Combination treatment with three or more antihypertensive drugs provides greater blood pressure (BP)-lowering effect than monotherapy, results of a study have shown. However, the net benefit may be lessened when side effects are considered.

The investigators searched electronic databases for BP-lowering randomized controlled trials (RCTs) comparing combination treatment or monotherapy with placebo, no treatment, or less-complex treatment.

Combination treatment was considered when background treatment continued during follow-up on top of the trial drug(s) of interest and drug(s) were added to the initial drug(s) of interest in most patients. Monotherapy was considered when prerandomization treatment was withdrawn or absent and a single drug was administered at randomization.

Of note, complexity of treatment refers to the higher averaged number of daily medications used in the eligible RCTs.

Ninety-three trials including 290,304 patients (follow-up, 3.9 years) were included in the analysis. The on-treatment mean number of drugs was 2.10 in the more actively treated patients and 0.99 in the less actively treated cohort.

Combination treatments of any complexity compared with placebo, no treatment, or less-complex treatment (mean number of drugs, 1.40 vs 0.41, 2.32 vs 0.48, 2.56 vs 1.62, and 3.14 vs 2.19, respectively) resulted in a reduction of all or most fatal and nonfatal outcomes.

However, an increased rate of side effects leading to treatment discontinuation was observed, but in absolute numbers the benefit usually outweighed the harm.

“Use of drug combinations is recommended by hypertension guidelines for most patients because of the greater BP-lowering effect compared with monotherapy,” the investigators said.