Trends in Initial Combination Antihypertensive Therapy in a US Health System

Initial combination therapy has been recommended for patients with high blood pressure (BP). We evaluated annual trends in initial combination therapy and post-treatment BP in Kaiser Permanente Southern California, an integrated healthcare system that adopted combination therapy in 2005.

This serial cross-sectional study included patients newly initiating antihypertensive therapy from 2008 to 2024. We calculated annual age- and sex-standardized proportion of patients initiating combination therapy. Prevalence ratios (PR) of achieving post-treatment BP <140/90 and <130/80 mm Hg between 6 and 12 months were estimated for initial combination versus monotherapy adjusting for demographic and pre-treatment BP.

Among 221,384 patients, the use of initial combination therapy increased from 39% in 2008 to 45% in 2011 (p-trend=0.009), then decreased to 27% in 2024 (p-trend <0.001). The decreasing trend of initial combination therapy from 2011 to 2024 was consistent across all pre-treatment systolic BP levels: 130-139 mm Hg (33% to 20%), 140-149 mm Hg (42% to 22%), 150-159 mm Hg (49% to 29%), and ≥160 mm Hg (61% to 36%). Post-treatment BP <140/90 mm Hg was 75% in 2011 and 66% in 2024; BP <130/80 mm Hg was 35% in 2011 and 25% in 2024. PRs for initial combination versus monotherapy were 1.09 (95% CI 1.08, 1.10) for post-treatment BP <140/90 mm Hg and 1.31 (95% CI 1.29, 1.33) for <130/80 mm Hg.

Although initial combination therapy remains associated with improved BP control, its use has declined in recent years, underscoring the importance of sustained support for guideline concordant care.