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single approach to improve adherence by the European Society of Cardiology [ 86 ].
Reducing dosing can be provided by the use of a fixed-dose combination (FDC)
polypill consisting of the recommended treatments in a single daily capsule. This
approach has improved adherence and reduced costs [ 87 – 90 ]. For this purpose,
Wald and Law have originally suggested a polypill that contains aspirin, thiazide,
β-blocker, ACE inhibitors, statin, and folic acid, in 2003 for primary prevention. A
simpler and more evidence-based formulation consisting of an aspirin, a statin, and
ACE inhibitors for the secondary prevention of cardiovascular (CV) events was
developed in Spain by a private–public partnership between the Centro Nacional de
Investigaciones Cardiovasculares (CNIC) and Ferrer Internacional [ 88 ]. This latter
polypill contains 100 mg aspirin, 20 mg atorvastatin, and 2.5, 5, or 10 mg ramipril.
Several studies have been reported on the efficacy, safety, tolerability, and afford-
ability of FDC polypills for the primary and secondary prevention of cardiovascular
diseases (CVD).
Several pilot studies have showed the feasibility of the primary prevention strat-
egy [ 91 – 94 ]. These are TIPS-1 (Indian Polycap Study) [ 91 ], PolyIran (Phase II
Study of Heart Polypill Safety and Efficacy in Primary Prevention of CV Disease)
[ 92 ], Combination Therapy Trial [ 93 ], and IMPACT (Improving Adherence Using
Combination Therapy) [ 94 ]. The large one TIPS-1 was a phase II randomized trial
that included 2053 participants aged 40–80 years without CVD and with at least one
CV risk factor in India [ 91 ]. The polypills used in those studies contained aspirin,
statin, ACE inhibitors, and thiazide diuretics at various doses. The outcomes of
those trials were feasibility, effect on risk factor levels, safety, and tolerability of
polypills.
The IMPACT (Improving Adherence Using Combination Therapy) trial included
513 adults at high risk of CVD (with established CVD or 5-year risk of ≥15%).
They were suggested for treatment with antiplatelet, statin, and ≥2 BP-lowering
drugs, and were randomized to continued usual care or to FDC treatment. The
investigators discovered that, parallel to other studies, adherence to all 4 suggested
drugs was greater among FDC than usual care participants at 12 months (81% vs.
46%; relative risk, 1.75 [95% confidence interval, 1.52 to 2.03]; p < 0.001) [ 94 ].
For secondary prevention, TIPS-2 (Second Indian Polycap Study) [ 95 ] reported
significant declines in BP and low density lipoprotein (LDL-C) in patients with
stable CVD or diabetes with the use of the combination drugs used in TIPS-1.
The UMPIRE (Use of a Multidrug Pill in Reducing Cardiovascular Events) study
that was the first randomized trial designed to detect the long-term effect of a FDC
strategy in improving patients’ adherence to medication in CV prevention has
recently announced [ 96 ]. Adherence to medication in the polypill group was 85%,
compared with 60% in the standard-care group (p < 0.001). BP and LDL-C levels
were decreased with the FDC strategy to a greater extent than with standard care.
No significant differences were noted in the incidence of serious adverse effects
between the groups [ 96 ].
The latest trial to investigate the effect on adherence of the polypill in secondary
prevention has just been noticed, and 623 patients with CVD or an estimated 5-year
CVD risk ≥15% were enrolled in this study. After a median of 18 months, patients
N. Keles et al.