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Meta-Analysis
. 2017 Jan 13;1(1):CD010316.
doi: 10.1002/14651858.CD010316.pub2.

First-line combination therapy versus first-line monotherapy for primary hypertension

Javier Garjón  1 , Luis Carlos Saiz  1 , Ana Azparren  1 , José J Elizondo  2 , Idoia Gaminde  3 , Mª José Ariz  4 , Juan Erviti  1
Affiliations
Meta-Analysis

First-line combination therapy versus first-line monotherapy for primary hypertension

Javier Garjón et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Starting with one drug and starting with a combination of two drugs are strategies suggested in clinical guidelines as initial treatment of hypertension. The recommendations are not based on evidence about clinically relevant outcomes. Some antihypertensive combinations have been shown to be harmful. The actual harm-to-benefit balance of each strategy is unknown.

Objectives: To determine if there are differences in clinical outcomes between monotherapy and combination therapy as initial treatment for primary hypertension.

Search methods: We searched the Hypertension Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, 2016, Issue 2), Ovid MEDLINE, Ovid Embase, LILACS, ClinicalTrials.gov, Current Controlled Trials, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to February 2016. We searched in clinical studies repositories of pharmaceutical companies, reviews of combination drugs in Food and Drug Administration and European Medicines Agency, and lists of references in reviews and clinical practice guidelines.

Selection criteria: Randomized, double-blind trials with at least 12 months' follow-up in adults with primary hypertension (systolic blood pressure/diastolic blood pressure 140/90 mmHg or higher, or 130/80 mmHg or higher if participants had diabetes), which compared combination of two first-line antihypertensive drug with monotherapy as initial treatment. Trials had to include at least 50 participants per group and report mortality, cardiovascular mortality, cardiovascular events or serious adverse events.

Data collection and analysis: Two authors independently selected trials for inclusion, evaluated the risk of bias and entered the data. Primary outcomes were mortality, serious adverse events, cardiovascular events and cardiovascular mortality. Secondary outcomes were withdrawals due to drug-related adverse effects, reaching blood pressure control (as defined in each trial) and blood pressure change from baseline. Analyses were based on the intention-to-treat principle. We summarized data on dichotomous outcomes as risk ratios with 95% confidence intervals.

Main results: We found three studies in which a subgroup of participants met our inclusion criteria. None of the studies focused solely on people initiating antihypertensive treatment so we asked investigators for data for this subgroup (monotherapy: 335 participants; combination therapy: 233 participants). They included outpatients, and mostly European and white people. Two trials included only people with type 2 diabetes, whereas the other trial excluded people treated with diabetes, hypocholesterolaemia or cardiovascular drugs. The follow-up was 12 months in two trials and 36 months in one trial. Certainty of evidence was very low due to the serious imprecision, and for using a subgroup not defined in advance. Confidence intervals were extremely wide for all important outcomes and included both appreciable harm and benefit.

Authors' conclusions: The numbers of included participants and, hence the number of events, were too small to draw any conclusion about the relative efficacy of monotherapy versus combination therapy as initial treatment for primary hypertension. There is a need for large clinical trials that address the question and report clinically relevant endpoints.

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Conflict of interest statement

None known.

Figures

Figure 1
Figure 1
Study flow diagram.
Figure 2
Figure 2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Analysis 1.1
Analysis 1.1
Comparison 1 Combination therapy versus monotherapy, Outcome 1 Total mortality.
Analysis 1.2
Analysis 1.2
Comparison 1 Combination therapy versus monotherapy, Outcome 2 Cardiovascular mortality.
Analysis 1.3
Analysis 1.3
Comparison 1 Combination therapy versus monotherapy, Outcome 3 Cardiovascular events.
Analysis 1.4
Analysis 1.4
Comparison 1 Combination therapy versus monotherapy, Outcome 4 Serious adverse events.
Analysis 1.5
Analysis 1.5
Comparison 1 Combination therapy versus monotherapy, Outcome 5 Withdrawals due to adverse effects.
Analysis 1.6
Analysis 1.6
Comparison 1 Combination therapy versus monotherapy, Outcome 6 Reaching target blood pressure at 1 year.
Analysis 1.7
Analysis 1.7
Comparison 1 Combination therapy versus monotherapy, Outcome 7 Systolic blood pressure change from baseline at end of 1 year.
Analysis 1.8
Analysis 1.8
Comparison 1 Combination therapy versus monotherapy, Outcome 8 Diastolic blood pressure change from baseline at end of 1 year.
Analysis 2.1
Analysis 2.1
Comparison 2 Combination therapy versus monotherapy (men versus women), Outcome 1 Serious adverse events.
Analysis 2.2
Analysis 2.2
Comparison 2 Combination therapy versus monotherapy (men versus women), Outcome 2 Withdrawals due to adverse effects.
Analysis 2.3
Analysis 2.3
Comparison 2 Combination therapy versus monotherapy (men versus women), Outcome 3 Systolic blood pressure change from baseline at end of 1 year.
Analysis 2.4
Analysis 2.4
Comparison 2 Combination therapy versus monotherapy (men versus women), Outcome 4 Diastolic blood pressure change from baseline at end of 1 year.
See this image and copyright information in PMC

References

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