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HT Update: CCB + RAAS blocker rather than RAAS + HCTZ may be the combination of choice for high CV risk hypertensive patients |
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HT Update: CCB + RAAS blocker rather than RAAS + HCTZ may be the combination of choice for high CV risk hypertensive patients

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Dr k k AggarwalGuidelines recommend combination therapy with complementary mechanism of actions in hypertension. The European guidelines further recommend a single pill combination to improve adherence. While calcium channel blockers (CCBs) and ARBs/angiotensin-converting enzyme (ACE) inhibitors are the preferred drug classes for combination, CCB and ARB combinations may be preferred over those containing ACE inhibitors due to superior tolerability and subsequent higher adherence.

Amlodipine, in combination with telmisartan, achieves better BP reduction with more patients achieving goal vs. monotherapies even in patients with renal impairment. Mean seated BP reductions of -25.7/-19.5mmHg and -26.5/-20.8 mmHg have been observed in patients with mild and moderate-to-severe renal impairment, respectively. In T2DM patients with stages 1 or 2 hypertension (SBP > 150 mmHg), 2-fold more patients achieved BP goal < 130/80mmHg vs. monotherapy. The combination also reduces the urine albumin to-creatinine ratio (UACR) by 70% compared with monotherapy.

Amlodipine-based combinations with RAAS inhibitors are associated with a significant risk reduction for renal disease progression, as well as CV disease events compared to the HCTZ-based combinations, most likely due to the metabolic or hemodynamic properties of the amlodipine-based combinations. In fact, thiazide diuretics may be associated with impairment of glucose homeostasis and greater incidence of diabetes compared with other antihypertensives.

Thus, CCB-RAAS blocker combinations, in general, and amlodipine + telmisartan, in particular, can help achieve further BP reductions whilst avoiding further metabolic disturbances and protecting the kidneys from further damage.

Reference: Mallat SG. What is a preferred angiotensin II receptor blocker-based combination therapy for blood pressure control in hypertensive patients with diabetic and non-diabetic renal impairment? Cardiovasc Diabetol. 2012Apr 10;11 :32. doi: 10.1186/1475-2840-11-32

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