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Use of fixed-dose combination antihypertensives in Germany between 2016 and 2020: an example of guideline inertia
Felix Mahfoud1, Marita Kieble2, Salka Enners2
1Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg/Saar, Germany. felix.mahfoud@uks.eu.
Insights
Fixed-dose combination (FDC) antihypertensive medications are underutilized despite 2018 guidelines recommending them. Data show a decline in FDC prescriptions, indicating a gap in implementing hypertension treatment guidelines.
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- The 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines advocate for fixed-dose combinations (FDCs) in hypertension management.
- Initial single-pill combination therapy is recommended for nearly all hypertensive patients.
- Clinical practice data on the implementation of these FDC recommendations are limited.
Purpose of the Study:
- To analyze the real-world utilization of antihypertensive fixed-dose combinations (FDCs) in Germany.
- To assess the adherence to 2018 ESC/ESH guidelines regarding FDC prescriptions.
- To identify trends in FDC dispensing patterns between 2016 and 2020.
Main Methods:
- Analysis of dispensed antihypertensive (AHT) FDC product data from the German Institute for Drug Use Evaluation (DAPI).
- Extrapolation of data to represent approximately 88% of the German population (around 73.3 million subjects).
- Examination of dispensing trends for all AHT FDCs from January 2016 to December 2020.
Main Results:
- The proportion of FDCs among all AHT prescriptions decreased from 15.4% in 2016 to 10.9% in 2020.
- Total AHT prescriptions increased slightly, but FDC dispensing declined from 22.2 million to 16.6 million packs.
- Dispensing of FDCs containing hydrochlorothiazide (HCT) significantly decreased, with its proportion in all FDCs dropping from 85.3% to 74.2%.
Conclusions:
- Two years post-guideline release, FDC utilization remains low at 10.9% in 2020, indicating underutilization of hypertension pharmacotherapy recommendations.
- A continuous decrease in FDC prescription rates was observed across different age groups, including those younger than 80 and older.
- Structured, evidence-based decision support programs are necessary to overcome guideline inertia and improve patient outcomes in hypertension management.
Background:
The 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guidelines for the management of hypertension highlight the importance of fixed-dose combinations (FDC) for the treatment of hypertension and recommend initial single-pill combination therapy in almost all patients. However, data on the implementation of these recommendations in clinical practice are scarce.
Methods:
Data from the German Institute for Drug Use Evaluation (DAPI) were analyzed and extrapolated accounting for approximately 88% of Germany's population (approximately 73.3 million subjects). All antihypertensive (AHT) FDC products available on the German market were included in the analyses. We examined the time course of dispensed packages between January 2016 and December 2020.
Results:
FDCs accounted for 15.4% of all AHT in 2016 and for 10.9% in 2020. While dispensing of all AHT increased slightly from year to year (2016: 143.8 million, 2020: 153.2 million packs), dispensing of FDCs decreased from 22.2 million (2016) to 16.6 million (2020) packs. Dispensing of FDCs containing hydrochlorothiazide (HCT) declined considerably from 2016 to 2020 (Q1 2016: 4.65 million, Q4 2020: 3.13 million packs). Accordingly, the proportion of HCT-containing combinations in all FDCs decreased from 85.3 to 74.2% from Q1 2016 to Q4 2020. Patients younger than 80 years were prescribed FDCs more frequently (14.6% of all AHT, based on the entire evaluation period) than patients 80 years and older (10.0%). In both age groups, this proportion decreased continuously over time.
Conclusions:
Almost 2 years following the release of the 2018 ESC/ESH guidelines, only 10.9% of the prescribed packs of antihypertensive drugs in 2020 were FDC products, documenting underutilization of current guideline recommendations on pharmacotherapy in hypertension. Structured programs to evidence-based decision support are required to improve guideline inertia and patient outcomes, eventually.
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