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In Brief | Cardiovascular Disease | Hypertension
Low-Dose Combination Therapy: A Viable Alternative to Traditional Hypertension Treatment in African Settings
Time to read: 03:35
Time to listen: 07:37
Originally Published: 29 January 2025
Sourced: JAMA Cardiology
Type of article: In Brief
MedED Catalogue Reference: MCIB005
Category: Cardiovascular Disease
Cross Reference: Gerontology
Keywords: hypertension, monotherapy, triple therapy
The findings of this study suggest that a two-pill low-dose combination could be just as effective as traditional stepped monotherapy in the management of hypertension.
This article is a review of recent studies originally published in JAMA Cardiology, This article does not represent the original research, nor is it intended to replace the original research. Access the full Disclaimer Information.
In the heart of rural Tanzania and Lesotho, where healthcare resources are often stretched thin, researchers set out to answer a critical question: Could a simple change in how hypertension is treated make a meaningful difference in blood pressure control?
Hypertension remains the leading cardiovascular risk factor in Africa, yet treatment strategies are often limited by accessibility, affordability, and effectiveness.
Study Purpose
The trial aimed to determine whether starting treatment with two antihypertensive drugs was at least as effective as standard monotherapy with dose escalation.
Its secondary outcome was to determine whether a low-dose, three-drug combination was superior in achieving blood pressure control.
ClinicalTrials.gov Identifier: NCT04129840
Study Methodology
Eligible participants were Black African adults with untreated, uncomplicated hypertension (≥140/90 mmHg).
Patients were randomised 2:2:1 to one of three treatment groups:
Treatment was adjusted monthly to reach target blood pressure (≤130/80 mmHg for those under 65, ≤140/90 mmHg for those 65 and older). The primary outcome was the proportion of participants achieving blood pressure targets at 12 weeks.
Findings
1,268 patients were enrolled in the study. The median age was 54 years and 914 (72%) patients were female.
Participants were assigned to one of three treatment groups: 505 received stepped monotherapy, 510 received the 2-pill strategy, and 253 received the 3-pill strategy.
At the end of the 12-week period, the following was recorded:
The two-pill strategy demonstrated noninferiority compared to stepped monotherapy, with 56% of participants achieving their target blood pressure versus 51% in the monotherapy group (adjusted odds ratio [aOR], 1.18; 95% CI, 0.87–1.61).
This finding suggests that initiating treatment with a combination of amlodipine and losartan at lower doses is at least as effective as the traditional stepped approach, where treatment is intensified only when blood pressure targets are not met.
The three-pill strategy, which included amlodipine, losartan, and hydrochlorothiazide at lower doses, resulted in 57% of participants achieving their target blood pressure. However, superiority analyses did not demonstrate a statistically significant advantage over the two-pill or stepped monotherapy strategies.
The adjusted odds ratio for the three-pill approach compared to monotherapy was 1.28 (95% CI, 0.91–1.79; P = .16), indicating that while numerically more participants reached their target, the difference was not statistically significant.
Discussion
These findings suggest that a two-pill low-dose combination could be just as effective as traditional stepped monotherapy—an important insight for hypertension management in African settings, where patients often struggle with access to consistent care.
However, while the three-pill approach didn’t prove superior in this trial, the study’s confidence intervals were broad, leaving room for the possibility that a more significant effect might exist in a larger or longer-term study.
Conclusion
Ultimately, this trial reinforces the idea that flexibility in hypertension treatment strategies is key—especially in resource-limited areas where the burden of uncontrolled blood pressure is high. By simplifying treatment approaches and making medications more accessible, healthcare providers may be able to help more people achieve better heart health with fewer hurdles.
Importance of this study for South Africa
Cardiovascular disease (CVD) remains a leading cause of mortality in South Africa, responsible for one in six deaths. Hypertension is the most significant modifiable risk factor for CVD, yet blood pressure (BP) control remains suboptimal.
In sub-Saharan Africa, the prevalence of hypertension is among the highest globally, while BP control rates are among the lowest.
Alarmingly, cardiovascular events in this region tend to occur approximately 15 years earlier than in other populations. National surveys in South Africa have reported a rising hypertension prevalence, from 38.4% in 2012 (SANHANES) to 48.2% in 2016 (DHS).1
These findings highlight an urgent need for improved hypertension control protocols, such as those evidenced in this trial,l to reduce the burden of CVD and improve long-term health outcomes.
Access the original study
Mapesi, H., Rohacek, M., Vanobberghen, F.et al (2025). Treatment Strategies to Control Blood Pressure in People With Hypertension in Tanzania and Lesotho: A Randomized Clinical Trial. JAMA cardiology, e245124. Advance online publication. https://doi.org/10.1001/jamacardio.2024.5124
Additional References
1 Woodiwiss, A.J., Orchard, A., Mels, C.M.C. et al. High prevalence but lack of awareness of hypertension in South Africa, particularly among men and young adults. J Hum Hypertens (2023). https://doi.org/10.1038/s41371-023-00873-3
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