The George Institute for Global Health, University of New South Wales, Hyderabad, India.
The George Institute for Global Health, University of New South Wales, Sydney.
J Hypertens. 2019 Aug;37(8):1567-1573. doi: 10.1097/HJH.0000000000002089.
Most patients with hypertension need at least two drugs to achieve goal blood pressure. This systematic review assessed efficacy and safety of triple versus dual combination therapy for the management of hypertension.
Publication databases, clinical trial registries and regulatory agency websites were searched until April 2018 for double-blind randomized controlled trials (RCTs) comparing triple with dual therapy of BP-lowering drugs, for at least 3 weeks, among patients with hypertension. Meta-analyses for efficacy and safety outcomes were performed using random-effects model. Regimen efficacy was predicted using the Therapeutic Intensity Score (TIS) and the Law et al. method (which predict dose doubling increases efficacy by 100% and around 20%, respectively), and compared with observed efficacy.
Fourteen RCTs (11 457 participants) were included. Overall, triple compared with dual therapy reduced BP by 5.4/3.2 mmHg (P < 0.001), and improved BP control by 58 versus 45% [relative risk (RR) 1.33 (95% CI 1.25-1.41)], whereas incidence of withdrawals because of adverse events were 3.3 versus 3.4% [RR 1.24 (95% CI 1.00-1.54), P = 0.05]. Law et al.'s method was superior to TIS in predicting differences in efficacy between triple and dual therapies. For patients uncontrolled on submaximal dose dual therapy, adding a third drug achieved on average approximately four times more BP reduction than doubling the dose of dual therapy component drugs (6.0/3.6 versus 1.5/0.8 mmHg, respectively).
Addition of a third drug is likely to be more efficacious without increasing adverse events, compared with increasing dose of existing dual therapy. Early use of triple therapy can significantly improve hypertension control.
大多数高血压患者需要至少两种药物才能达到目标血压。本系统评价评估了三联与双联降压药物治疗方案治疗高血压的疗效和安全性。
检索了截至 2018 年 4 月的出版文献数据库、临床试验注册库和监管机构网站，以获取比较三联与双联降压药物治疗方案、治疗时间至少 3 周的高血压患者的双盲随机对照试验（RCT）。使用随机效应模型进行疗效和安全性结局的荟萃分析。使用治疗强度评分（TIS）和 Law 等人的方法（分别预测剂量加倍增加疗效 100%和 20%左右）预测方案疗效，并与观察到的疗效进行比较。
共纳入 14 项 RCT（11457 名参与者）。总体而言，与双联治疗相比，三联治疗可使血压降低 5.4/3.2mmHg（P<0.001），血压控制率提高 58%比 45%[相对风险（RR）1.33（95%CI 1.25-1.41)]，而因不良反应而停药的发生率为 3.3%比 3.4%[RR 1.24（95%CI 1.00-1.54），P=0.05]。Law 等人的方法在预测三联与双联治疗方案疗效差异方面优于 TIS。对于亚最大剂量双联治疗未控制的患者，添加第三种药物平均可使血压降低约四倍，而不是将双联治疗药物剂量加倍（分别为 6.0/3.6 与 1.5/0.8mmHg）。
与增加现有双联治疗剂量相比，添加第三种药物可能更有效而不会增加不良反应。早期使用三联治疗可显著改善高血压控制。
