Efficacy and Safety of a Novel Low-Dose Triple Single-Pill Combination Compared With Placebo for Initial Treatment of Hypertension.

Background: Single-pill combinations of 3 or more low-dose blood pressure (BP)-lowering drugs hold promise for initial or early treatment of hypertension.
Objectives: We conducted a placebo-controlled trial of a new single-pill combination containing low doses of telmisartan, amlodipine, and indapamide in 2 dose options to assess efficacy and safety.
Methods: This international, randomized, double-blind, placebo-controlled, parallel-group trial enrolled adults with hypertension receiving 0 to 1 BP-lowering drugs. After a 2-week placebo run-in during which any BP-lowering medication was stopped, participants were eligible if home systolic BP (SBP) was 130 to 154 mm Hg. Participants were randomized in a 2:2:1 ratio to GMRx2 ¼ dose (telmisartan 10 mg/amlodipine 1.25 mg/indapamide 0.625 mg), GMRx2 ½ dose (telmisartan 20 mg/amlodipine 2.5 mg/indapamide 1.25 mg), or placebo. The primary efficacy outcome was difference in change in home SBP from randomization to week 4, and primary safety outcome was treatment discontinuation due to an adverse event.
Results: From June 14, 2021 to October 18, 2023, a total of 295 participants (mean age: 51 years; 56% female) were randomized and 96% completed the trial. Baseline mean home BP was 139/86 mm Hg and clinic BP was 138/86 mm Hg after placebo run-in. The placebo-corrected least square mean differences in home SBP at Week 4 were -7.3 mm Hg (95% CI: -4.5 to -10.2) for GMRx2 ¼ dose and -8.2 mm Hg (95% CI: -5.2 to -11.3) for GMRx2 ½ dose; reductions for clinic BP were 8.0/4.0 and 9.5/4.9 mm Hg. At Week 4, clinic BP control (<140/90 mm Hg) was 37%, 65%, and 70% for placebo, GMRx2 ¼ dose, and GMRx2 ½ dose, respectively (both doses P < 0.001 vs placebo). Placebo, GMRx2-triple ¼, and GMRx2 ½ treatment discontinuation due to an adverse event occurred in 1 (1.6%), 0, and 6 (5.1%), respectively; out of normal range serum sodium or potassium was observed in 4 (6.3%), 12 (10.6%), and 12 (10.1%), respectively, but no participant had a serum sodium <130/>150 mmol/L or potassium <3.0/>6.0 mmol/L. Serious adverse events were reported by 2 participants in the placebo and GMRx2 ½ groups and none in the GMRx2 ¼ group.
Conclusions: In a population with mild-to-moderate BP elevation, both dose versions of the novel low-dose triple single-pill combination showed good tolerability and clinically relevant BP reductions compared with placebo. (Efficacy and Safety of GRMx2 Compared to Placebo for the Treatment of Hypertension: NCT04518306).
Competing Interests: Funding Support and Author Disclosures This trial was funded by George Medicines Pty Ltd (GM). The trial was designed by The Steering Committee, who were responsible for the study protocol. The funder of the study consulted with the U.S. Food and Drug Administration to ensure the trial design was suitable to inform an application for regulatory approval; the funder GM provided comments on a draft of the publication. The Steering Committee had full access to all the data, wrote and had final responsibility for the publication. Prof Rodgers, Dr Salam, Prof Schutte, C. ianacas, M. Shanthakumar, Dr Liu, and Dr Wang are employed at The George Institute for Global Health (TGI), which holds an interest in GM via its social enterprise arm, George Institute Ventures. None of the TGI staff have any personal financial interest in GM. Prof Rodgers is seconded part-time to GM. TGI holds patents for ultra -low-dose fixed-dose combination products for the treatment of hypertension and diabetes, and Prof Rodgers is listed as one of the inventors (granted: U.S. 10,369,156; U.S. 10,799,487; U.S. 10,322,117; U.S. 11,033,544; U.S. 11,478,462; pending: U.S. 17/932,982; U.S. 18/446,268; U.S. 17/ 598,122; U.S. 17/317,614; U.S. 17/527,084; U.S. 17/527,085; U.S. 17/ 527,087). Prof Rodgers does not have a financial interest in these patents. None of the other authors have a financial interest in GM or have received funding for their independent contribution to the GMRx2 program. Dr Schutte has received consulting fees and/or speaker honoraria from Omron Healthcare, Aktiia, Medtronic, Servier, Abbott, Sanofi, Sun Pharmaceuticals, Novartis, and Skylabs; is co-chair of the National Hypertension Taskforce of Australia; is a board member of Hypertension Australia, and Australian Cardiovascular Alliance; and is supported by an investigator grant from the National Health and Medical Research Council of Australia (GNT 2017504). Dr Ojji has received speaker honoraria from Novartis, AstraZeneca, Servier, Swipha, and Boehringer Ingelheim for speaking at educational meetings. Dr Narkiewicz has received speaker and consulting honoraria from Bausch Health, Berlin-Chemie/Menarini, Egis, Gedeon Richter, Gilead, Idorsia, Janssen, Krka, Novo Nordisk, Polpharma, Recordati, Sandoz, Servier, and Zentiva. Dr Schlaich has received consulting fees, and/or travel fees and research support from Medtronic, Abbott, ReCor, Novartis, Servier, Pfizer, and Boehringer Ingelheim; and is the current president of Hypertension Australia and Treasurer of the World Hypertension League. Dr Cushman has received institutional grants from Recor Medical and George Medicines; and has received consulting fees from Alnylam Pharmaceuticals. Dr Poulter has received financial support from several pharmaceutical companies that manufacture BP-lowering agents; has received consultancy fees from Servier and Aktiia; has received consultancy fees for research projects and staff from Servier and Pfizer; has received consultancy fees for arranging and speaking at educational meetings from AstraZeneca, Lri Therapharma, Napi, Servier, Sanofi, Eva Pharma, Pfizer, Emcure India, Dr Reddy's Laboratories, and Zydus; and has received support from the National Institute for Health Research Senior Investigator Awards, Biomedical Research Centre funding, and the British Heart Foundation Research Centre Excellence Award. Dr Wright has received support from NIH, Ohio Department of Medicaid, Agency for Health Care Research and Quality, Medtronic, Inc, and the Northeast Ohio Neighborhood Health Center Community Board of Directors. Dr Grobbee receives funding to his department as part of the EU Horizon Hypermarker project. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
(Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)