Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
Am J Cardiovasc Drugs. 2011;11(1):21-32. doi: 10.2165/11586570-000000000-00000.
Evidence is currently equivocal on the added benefits of dual blockade of the renin-angiotensin-aldosterone system with the combination of either an ACE inhibitor (ACEI) plus an angiotensin II type 1 receptor antagonist (angiotensin receptor blocker [ARB]) or aliskiren, the first-in-class direct renin inhibitor, plus an ARB.
To compare the compliance, persistence, healthcare resource utilization, and healthcare costs associated with aliskiren plus ARB versus ACEI plus ARB combination therapies among adult patients diagnosed with hypertension.
Patients (aged ≥18 years) initiated on either combination therapy were identified in the MarketScan Commercial and Medicare Supplemental Databases (1 July 2007 to 30 June 2008). The ARB components considered were candesartan, irbesartan, losartan, olmesartan, telmisartan, and valsartan. The ACEI components included benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, and trandolapril. Outcomes measured during the 6-month study period included the proportion of days covered (PDC), treatment discontinuation, healthcare resource utilization, and changes in healthcare costs (study period minus 6-month baseline values). Risk-adjusted differences in outcomes between treatments and associated 95% confidence intervals (CIs) were estimated using multivariate regression models, controlling for demographics, region, co-morbidities, prescription drug use, and resource utilization during the baseline period.
Adjusting for baseline characteristics, aliskiren plus ARB patients (n = 1395) demonstrated a significantly higher PDC (67.0% vs 54.3%; difference 12.7%; 95% CI 10.6, 14.7) and a significantly lower discontinuation rate (50.4% vs 68.6%; odds ratio 0.46; 95% CI 0.40, 0.54) than ACEI plus ARB patients (n = 16 507). Aliskiren plus ARB patients had significantly fewer all-cause hospitalizations (adjusted incidence rate ratio [IRR] 0.73; 95% CI 0.61, 0.86) and significantly fewer all-cause emergency room (ER) visits (adjusted IRR 0.72; 95% CI 0.61, 0.85) than ACEI plus ARB patients. Compared with ACEI plus ARB therapy, aliskiren plus ARB therapy was associated with significantly larger increases in prescription costs by $US264 post therapy initiation (95% CI 153, 375), but with non-significantly greater reductions in total healthcare costs by -$583 (95% CI -2409, 1242).[2008 values].
In adult hypertensive patients, treatment with aliskiren plus ARB was associated with significantly better compliance/persistence and fewer hospitalizations and ER visits compared with ACEI plus ARB therapy. Reductions in total healthcare costs were non-significantly different between patients treated with aliskiren plus ARB versus ACEI plus ARB, despite the increased prescription costs associated with aliskiren plus ARB therapy.
目前，关于联合使用肾素-血管紧张素-醛固酮系统双重阻断剂（ACEI 加血管紧张素 II 型 1 型受体拮抗剂 [ARB] 或直接肾素抑制剂阿利克仑加 ARB）与 ACEI 加 ARB 联合治疗的额外益处的证据尚无定论。
比较高血压患者中阿利克仑加 ARB 与 ACEI 加 ARB 联合治疗的依从性、持久性、医疗资源利用和医疗成本。
在 MarketScan 商业和医疗保险补充数据库（2007 年 7 月 1 日至 2008 年 6 月 30 日）中确定了开始接受这两种联合治疗的患者。所考虑的 ARB 成分包括坎地沙坦、厄贝沙坦、氯沙坦、奥美沙坦、替米沙坦和缬沙坦。ACEI 成分包括贝那普利、卡托普利、依那普利、福辛普利、赖诺普利、莫昔普利、培哚普利、喹那普利、雷米普利和群多普利。在 6 个月的研究期间，评估的结果包括天数覆盖率（PDC）、治疗中断、医疗资源利用和医疗成本变化（研究期间减去 6 个月的基线值）。使用多元回归模型，在控制基线期人口统计学、地区、合并症、处方药使用和资源利用的情况下，估计治疗之间风险调整后结果的差异及其 95%置信区间（CI）。
调整基线特征后，与 ACEI 加 ARB 患者（n=16507）相比，阿利克仑加 ARB 患者（n=1395）的 PDC 明显更高（67.0% vs 54.3%；差异 12.7%；95%CI 10.6，14.7），停药率明显更低（50.4% vs 68.6%；比值比 0.46；95%CI 0.40，0.54）。与 ACEI 加 ARB 患者相比，阿利克仑加 ARB 患者的全因住院治疗（调整后的发病率比 [IRR] 0.73；95%CI 0.61，0.86）和全因急诊就诊（调整后的 IRR 0.72；95%CI 0.61，0.85）明显减少。与 ACEI 加 ARB 治疗相比，阿利克仑加 ARB 治疗后，处方费用增加了 264 美元（95%CI 153 美元，375 美元），而总成本医疗费用减少了 583 美元（95%CI-2409 美元，1242 美元）。[2008 年的数值]。
在成年高血压患者中，与 ACEI 加 ARB 治疗相比，阿利克仑加 ARB 治疗具有更好的依从性/持久性，并且住院和急诊就诊次数更少。尽管阿利克仑加 ARB 治疗的处方费用增加，但与 ACEI 加 ARB 治疗相比，患者的总医疗成本降低并不显著。
