Combination Therapy vs. Monotherapy

Monotherapy is a type of treatment which uses a single agent drug acting in a particular way for treatment. Since multiple factors contribute to hypertension, it may not be possible to control high blood pressure with monotherapy.

Combination therapy, which uses regimens involving fixed-dose combinations (FDC) or regimens that have ‘drugs added sequentially one after other’, is now favored by the medical fraternity to treat hypertension.

Combination therapy is better than monotherapy because -

Drugs are available in a convenient dosing format; and
Drugs cause fewer side effects because of the lower dose of individual component.

Further, a US interactive survey for hypertension revealed that majority of hypertensive patients did not go in for any lifestyle change and relied just on medication for the control of their high blood pressure.

In a recent paper published in the journal Hypertension, researcher Brent Egan from the Department of Medicine, Medical University of South Carolina, and colleagues showed that ‘Initial therapy with single-pill combinations provided better hypertension control in the first year than free combinations or monotherapy with benefits in black and white patients’. Other studies have found better cardiovascular outcomes with single-pill combination therapy for hypertension.

However, Dr Alan H Gradman, from Western Pennsylvania Hospital, Pittsburgh, pointed out that even though single pill combination therapy could be an attractive option that would improve compliance, the cost factor could be a critical issue for many patients since most of these pills are branded combinations and are often more expensive.

American Society of Hypertension (ASH) recommended the following drug combinations in hypertension -

Drug combinations in hypertension: Recommendations of ASH
Preferred 2-drug combinations	Acceptable 2-drug combinations	Unacceptable 2-drug combinations
ACE inhibitor/diuretic*	Beta-blocker/diuretic*	ACE inhibitor/ARB
ARB/diuretic*	CCB/diuretic	ACE inhibitor/beta blocker
ACE inhibitor/CCB*	Renin inhibitor/diuretic	ARB/beta blocker
ARB/CCB*	Thiazide diuretic/potassium-sparing diuretic	CCB (nonhydropyridine)/beta blocker
		Centrally acting agent/beta blocker