More drugs? Yes please! It has been found that a combination of two antihypertensive drugs to combat high blood pressure and hypertension from the start is better than using a monotherapy method or adding an additional prescription later in the treatment. These elements combined both decrease renin production, which regulates pressure, while simultaneously smoothing arterial walls for better blood flow.

The combination of aliskiren and amlodipine are the best mix of prescribed treatments according to an ACCELERATE study are reported in an Article Online First and an upcoming Lancet. The Article is by Prof Morris J Brown, Addenbrooke’s Hospital, Cambridge and University of Cambridge, UK, and colleagues from the British Hypertension Society and Novartis.

Many drugs control blood pressure by interfering with angiotensin or aldosterone. However, when these drugs are used chronically, the body increases renin production, which drives blood pressure up again. Therefore, doctors have been looking for a drug to inhibit renin directly. Aliskiren is the first drug to do so.

Amlodipine is a long-acting calcium channel blocker (dihydropyridine class) used as an anti-hypertensive and in the treatment of angina. Like other calcium channel blockers, amlodipine acts by relaxing the smooth muscle in the arterial wall, decreasing total peripheral resistance and hence reducing blood pressure, while in angina it increases blood flow to the heart muscle.

In the study, all patients had high systolic blood pressure between 150 and 180 mm Hg (normal blood pressure is usually below 140 mm Hg systolic). Blood pressure numbers include systolic and diastolic pressures. Systolic blood pressure is the pressure when the heart beats while pumping blood. Diastolic blood pressure is the pressure when the heart is at rest between beats.

The study compared the drugs aliskiren and amlodipine, with 620 patients assigned to monotherapy with either drug or a combination of both for 16 weeks. After those 16 weeks, those on monotherapy switched to combination therapy while those on combination therapy already continued.

The authors state:

“ACCELERATE is the first trial to test the medium-term efficacy and safety of full doses of two antihypertensive drugs as first-line treatment for patients with a systolic blood pressure greater than 150 mm Hg, by comparison with sequential add-on treatment with the same drugs. We believe that routine initial reduction in blood pressure (>150 mm Hg) with a combination such as aliskiren plus amlodipine can be recommended.”

Researchers found that patients given initial combination therapy had a mean 6•5 mm Hg greater reduction in mean systolic blood pressure than the monotherapy groups. At 24 weeks, when all patients were on combination treatment, the difference had decreased to 1•4 mm Hg.

Dr. Ivana Lazich, and Dr. George Bakris, University of Chicago Hypertensive Diseases Unit, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, USA conclude:

“ACCELERATE puts into proper context the importance of starting with combination antihypertensives to lower blood pressure towards guideline goals for the general population… A change in guidelines is clearly necessary after the ACCELERATE report.”

Prof Morris J Brown, Addenbrooke’s Hospital, Cambridge and University of Cambridge, UK

Dr George Bakris, University of Chicago Hypertensive Diseases Unit, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, USA

For full report from the Lancet, click here: ACCELERATE

Written by Sy Kraft, B.A.