◆Combination Treatment


The importance of combination treatment is emphasized in both the European and the JNC 7 guidelines. However, the ESH/ESC guidelines have a new element, in that they say that since combination treatment is so important and so prevalent, physicians should be given the option to start with combination treatment. So one of the flow charts in the guidelines gives 2 options, monotherapy or low-dose combination, and the advantages and disadvantages of each option are outlined.

An obvious disadvantage of starting with a low-dose combination is that some patients may be on 2 drugs even though they could get their blood pressure under control with 1. The advantage is faster blood pressure control, which has favorable psychological reflection on both the patient and the physician. Low dose means probably less chance of side effects and better compliance.
The new guidelines also outline the criteria for when the doctor may want to start with a low-dose combination or with monotherapy -- for example, the blood pressure level. If the blood pressure is quite high, the patient is going to require 2 or 3 drugs eventually, and it may seem like a waste of time to start the patient on a single drug. Then again, if the patient is at high risk (even with a more moderate blood pressure), he/she needs blood pressure control quickly, and it seems unnecessary to wait 3-5 months before achieving control.

Professor Mancia believes that these criteria could endorse physicians' preference to combination treatment as the first step. Furthermore, as he pointed out, underuse of combination treatment by physicians has been shown to be one of the possible reasons for poor blood pressure control. The guidelines mention that fixed-dose combinations could increase compliance by simplifying treatment, but otherwise they take no firm position about whether these fixed combinations should be the regular strategy.

编辑 郑麓薇