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| Archive : Winter 2007 |
RADICAL VISION:
A cocktail of cardiovascular drugs // Recommended for everyone over 55 // No prescription necessary // No need for a doctor’s oversight // The brainchild of overly ambitious would-be pioneers, or truly
the world’s next wonder drug?
The Polypill [page 2]
 By Rachael Moeller Gorman |
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Eventually, the Polypill team members want their pill to be available over the counter, like a multivitamin. And since measuring such risk factors as blood pressure and cholesterol only add cost while unnecessarily restricting treatment, they don’t envision involving physicians. That way, the Polypill proponents believe, their approach could save innumerable lives at a manageable cost, particularly because many of the drugs they would prescribe are, or soon will be, off patent.
For a tool that’s supposed to eliminate virtually all heart disease and stroke, the Polypill is a remarkably modest concoction. It combines what were once considered miracle drugs, but now are more or less taken for granted as effective means for reducing blood pressure and cholesterol levels. Those reductions have already translated into somewhat lower levels of cardiovascular disease. A 2001 paper in the Journal of the American College of Cardiology found that heart disease in the United States between 1981 and 1990 dropped by approximately 7% to 11%. More than half the improvement was attributed to a reduction in diastolic blood pressure, while 38% came from reduced cholesterol levels.
Though encouraging, those gains don’t come close to what Nicholas Wald and Law believe is possible. Based on their review of trial data in the 2003 BMJ paper, they surmise that, taken long enough, a statin that cuts cholesterol by 1.8 millimoles per liter would reduce heart disease risk by 61%, while drops of 20 and 11 millimeters of mercury, respectively, in systolic and diastolic blood pressure, could push down heart disease risk by 46%.
Some experts dispute that analysis and maintain that statins would cut risk by only 35% and blood pressure drugs by 20%. But Wald and Law contend that statins don’t achieve their full effect until they’ve been taken for at least two years, and the duo’s 61% figure is for those who have crossed that threshold. They also assumed that the combination of three blood pressure drugs would have a greater impact than using just one, because previous trials on multiple blood-pressure-lowering drugs show additive effects. The alternative analysis predicted a smaller effect, essentially the benefit of taking just one blood pressure reducer.
Whatever the correct calculation, real-world gains have been much smaller because most people don’t achieve the necessary reductions in cholesterol and blood pressure. Despite effective therapies, only 34% of people with high blood pressure and 18% with high cholesterol have their conditions under control.
So, the first step in improving cardiovascular outcomes is to get everyone to take the drugs that could help them. According to generally accepted guidelines, candidates for treatment include anyone whose LDL cholesterol is higher than 100 or whose blood pressure is higher than 140/90. Wald and Law want to go further, giving statins and blood pressure medication even to people whose readings are below those levels but who are over age 55 because, they contend, a lifetime of exposure to our modern world elevates these levels to some degree, forcing everyone down the road to heart disease. Moreover, they say that combining the medication in a single pill will make it much more likely that people will stick to the regimen.
Other combination pills are already on the market, including one that brings together two asthma medications and another that combines three HIV drugs. To determine the best formula for the Polypill, Wald and Law went through a lengthy process detailed in the other papers published in the 2003 issue of the BMJ. First, they sifted through 354 randomized, double-blind, placebo-controlled trials of the five main categories of blood pressure drugs: thiazides (diuretics that prevent the kidneys from absorbing sodium); beta-blockers (which prevent substances like adrenaline from stressing the heart); angiotensin converting enzyme (ACE) inhibitors (compounds that block formation of angiotensin in the kidneys, thus relaxing arteries and promoting excretion of salt and water); angiotensin II receptor antagonists (which block receptors so angiotensin II cannot constrict blood vessels and thus increase blood pressure); and calcium-channel blockers (which keep calcium from entering heart and vessel walls, thus widening and relaxing vessels). |
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Illustrations by Christoph Niemann |
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