Not a week after a current review of compelling new evidence for lowdose old drug combination (reserpine plus amilozide) for hypertension, a ‘Best Practice’ newsletter email purportedly from the South African Hypertension Society SAHS arrives from Novartis(-Sandoz-Ciba) – a giant front-page advertorial for it’s hoped-for raincheck Exforge.
The good SAHS article on Drug Therapy of Hypertension concludes what we have learnt for years from treatment of eg TB, AIDS, rheumatoid arthritis and peptic ulcer – that Triple Therapy is far more successful compared to the mediocre control with even double antihypertensive therapy. But all hypertension advice must include, apart from diet-lifestyle counselling, fish oil and lowdose thiazide as bedrock.
Hypertension is said/ projected o affect up to 1 in 4 people worldwide, or between 20 and 45% of people over the age of 20yrs on the different continents; and is essential ie no specific single disease cause found in over 90% . While the prime major degenerative disease factor that greatly reduces healthspan and lifespan – increasing overweight- is visible to all from the obvious marker (waist girth) , systemic hypertension is often clinically silent until huge damage is done, unless bloodpressure is simply measured (along with bodymass index or, better, also waist girth) at least every two years.
This screening takes negligible bother, timecost and training. In a region such as Africa where hypertension and overweight are endemic, all it would take to expose the mountain of reversible disease would be to make it compulsory for every citizen to submit annually or every 2 years, or even just at every election or census time, a postcard (or email) to a central registry of one’s identity number (ie birthdate), digital automated bloodpressure reading from say age 5years, plus annual waist girth in all over the age of eg 8 years. All it would then require would be the local eg Regional area computer Registry to regularly spit out the details of anyone who exceeds simple preset limits (or who does not send in his details at least every two years), to have the patient/parent notified to report to a health practitioner for appropriate advice against hypertension and overweight and if necessary lowcost goldstandard therapy eg fish oil, metformin and reserpine-amilozide. It simply needs local agreement as to whether even prehypertension (ie above the threshold of 119/79) let alone stage 1 hypertension (>139 systolic or > 89 diastolic) is to be called.
Reserpine and thiazides have been thoroughly tested since the mid-1950s and amiloride and spironolactone since the mid-1960s. Spirolactone may be best against heart failure- but why risk it’s antiandrogen and carcinogenic effects for uncomplicated hypertension? The best simple safe triple therapy – reserpine, with amilozide– hydrochlorothiazide and amiloride – has thus been freely available in South Africa for 40 years, costs an average of no more than R10 a month retail (R35 every 4 months), and controls most patients with simple dose titration, practically no adverse symptoms, metabolic effects, and zero life-threatening risks such as angiotensin- and beta-blockers have. It reverses most major practical central and peripheral end- mechanisms ie salt -water retention, magnesium-potassium depletion, vasoconstriction, and hyperdynamic factors.
Leading members of SAHS like Profs YK Seedat (Univ Kwazulu-Natal); Harry Seftel (Univ Wits); Willie Overmeyer(univ Free State); and Roy Keeton and Marc Blockman (Univ Cape Town) agreed with this at the Cape Town SAHS meeting a few years ago. Nothing has changed since, in fact the evidence has increased against 1st- or 2nd-line therapy with Angiotensin blockers, betablockers and diuretic doses of thiazides-type drugs.
This combination- lowdose reserpine (eg 0.0625 mg 3 times a week to 0.125mg daily) plus lowdose eg amilozide/coamiloretic (HCT+amiloride 13.625mg 3x/week to 27.5mg daily) used to be available as eg Protensin, Rautrax improved, Brinerdin, Adelphane esidrex), but thanks to obvious collusion between Manufacturers of more modern ie profitable drugs that need to be sold, and their paid lobbyists in academie and clinical practice, the proven old drugs have been removed from Recommended Drug lists and even from State Codes.
State “Authorities” and SAHS refuse to quote any evidence to justify this suppression of combined lowdose reserpine -amilozide- coamiloretic – because there are no trials or reasons justifying such fraudulent ditching of what has worked best for decades.. The advantage of separate reserpine 0.25mg and amilozide 55mg tablets that can each be broken into quarters is obvious, since it gives flexibility in titration- some patients end up needing no more than 1/4 tablet of each 3 days a week. With sensible advice about salt, sugar, smoking, weight loss, exercise, alcohol, weight loss and dose , addition of a 4th drug is seldom needed.
Abundant trials confirm the primacy of this available triple regime, and can be read on line at TIME TO COMPEL LOWDOSE RESERPINE AND LOWDOSE AMILOZIDE AS FIRST LINE THERAPY OF AVERAGE HYPERTENSION.
It is a sad day indeed when a professional society- SAHS – surely debases itself by having it’s Newsletter send out as an advertorial by, for and from a drug company (ie sent from firstname.lastname@example.org.).
Unfortunately www.hypertension.org.za/ and www.novartis.co.za/ – and thus the SAHS Best Practice newsletter in question- are both off line, unsurprisingly since Novartis apparently hosts the SAHS newsletter if not website. . National and international hypertension societies and regulators should surely above all else be independent of drug peddlers, should be promoting evidence-based medicine in the interests of patients, not profits . But only the USA and eastern countries do so, still allow reserpine.
In fact the latest Pubmed review shows that Exforge – at huge retail cost- is no better than any other 2-drug combination – and it was no more than “generally well tolerated”. In fact on the Internet and in MIMS, numerous severe contra-indications, side-effects and special precautions. of Exforge are listed – not all of them dose-dependent ..
No matter how rare serious complications of drugs are, why risk death by angioedema, kidney failure or astnma by advocating an angiotensin- or beta- blocker as anything but last-ditch therapy of common essential hypertension? Pubmed shows at least 6 reports of valsartan-associated angioedema in less than 12 years since its introduction. Drugs which are notoriously known to cause cough (ABs- angiotensin blockers) let alone dyspnoea (betablockers) and insidiously progressive renal failure (angiotensin blockers) have no place in the treatment of uncomplicated hypertension.
It is common cause that lowdose reserpine and lowdose potassium-sparing thiazide combination are the only antihypertensive drugs that significantly lower all-cause mortality and dementia.
If SAHS and the SAMJ fail to publish this warning promptly- rebutting the clinically seriously misleading marketing email promoting Exforge (ostensibly from SAHS but sent by Novartis) – then the Advertising Standards Association, the Medical Association and Medicines Control Council must take action in the interests of patients.