Amlodipine plus either hydrochlorothiazide or perindopril effectively reduced blood pressure better than perindopril and hydrochlorothiazide in black African patients with hypertension, based on data presented at the annual meeting of the American College of Cardiology.
“(A) long-acting dihydropyridine calcium-channel blocker (in this case, amlodipine) may be critical to more efficacious blood-pressure lowering among black patients as part of the two-drug combinations used (in Africa),” wrote lead author Dike B. Ojji, PhD, of the University of Abuja in Gwagwalada, Abuja, Nigeria, and his coauthors. “These results contrast with recommendations for black patients in the most recent U.S. guidelines” which recommend either a calcium channel blocker or a diuretic in combination with a different drug class.
The study was published simultaneously in the New England Journal of Medicine.
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Blood pressure gauge
In the CREOLE study, Dr. Ojji and his colleagues enrolled 728 black patients, mean age 51 years and 63% of them women, in a randomized, single-blind, three-group trial across six countries in sub-Saharan Africa. All patients had uncontrolled hypertension and were assigned to one of three treatment groups: amlodipine plus hydrochlorothiazide (n = 244), amlodipine plus perindopril (n = 243), and perindopril plus hydrochlorothiazide (n = 241). Patients underwent 24-hour ambulatory blood-pressure measuring at baseline and at 6 months.
Of the 621 patients who completed the trial, those in the two groups receiving amlodipine had a larger mean reduction in systolic blood pressure after 6 months than the group receiving perindopril plus hydrochlorothiazide. Compared with the perindopril plus hydrochlorothiazide group, the amlodipine plus hydrochlorothiazide group had an additional -3.14 mm Hg reduction in systolic blood pressure from baseline (95% confidence interval, -5.90 to -0.38, P = 0.03) while the amlodipine plus perindopril group had an additional -3.00 mm Hg reduction (95% CI, -5.81 to -0.20, P = 0.04). The difference between the amlodipine plus hydrochlorothiazide group and the amlodipine plus perindopril group was -0.14 mm Hg (95% CI, -2.90 to 2.61, P = 0.92).
The limitations of the study included using nonmatching trial drugs and not adjusting the P values for the three comparisons of the primary end point, the authors wrote. It’s uncertain whether the findings can be extrapolated to black patients with diabetes or to those living outside of sub-Saharan Africa.
The study was sponsored by a grant from the GlaxoSmithKline Africa Noncommunicable Disease Open Lab. Trial drugs were donated by Aspen Pharmacare. Two authors reported receiving grants and personal fees from numerous pharmaceutical companies.
SOURCE: Ojji DB et al. NEJM. 2019 Mar 18. doi: 10.1056/NEJMoa1901113.