Combination therapies for hypertension - why we need to look beyond RAS blockers.

INTRODUCTION: Hypertension is the leading cause of mortality and disability worldwide. Despite the proven benefits of blood pressure (BP) reduction, lack of BP pressure control continues to be the most important clinical problem in hypertension management. Areas covered: Factors involved in the lack of BP control and strategies to improve such control have been reviewed, with special focus on the usefulness of combination therapies, those types of combination which include a renin-angiotensin system (RAS) blocker, with diuretics, calcium channel blockers, or both. Expert commentary: Combination therapy is required for BP control in most hypertensive patients. RAS blockers should be included in such combinations, except contraindicated. Diuretics, and especially calcium channel blockers are the drugs of choice for double or triple combinations. Diuretics stimulate RAS and enhance the effect of RAS blockers, while minimizing the undesirable metabolic effects of diuretics. RAS blockers and calcium channel blockers have synergistic protective effects on the vascular wall and have demonstrated to be superior to other types of combinations, thus becoming the preferred initial treatment for most hypertensive patients. The use of single-pill combinations is associated with better treatment adherence, thus facilitating the achievement of adequate BP control.