Pharmacotherapy for hypertension in Sub-Saharan Africa: a systematic review and network meta-analysis

Abstract

Background: The highest burden of hypertension is found in Sub-Saharan Africa (SSA) with a threefold greater mortality from stroke and other associated diseases. Ethnicity is known to influence the response to antihypertensives, especially in black populations living in North America and Europe. We sought to outline the impact of all commonly used pharmacological agents on both blood pressure reduction and cardiovascular morbidity and mortality in SSA. Methods: We used similar criteria to previous large meta-analyses of blood pressure agents but restricted results to populations in SSA. Quality of evidence was assessed using a risk of bias tool. Network meta-analysis with random effects was used to compare the effects across interventions and meta-regression to explore participant heterogeneity.Results: Thirty-two studies of 2860 participants were identified. Most were small studies from single, urban centres. Compared with placebo, any pharmacotherapy lowered SBP/DBP by 8.51/8.04 mmHg, and calcium channel blockers (CCBs) were the most efficacious first-line agent with 18.46/11.6 mmHg reduction. Fewer studies assessing combination therapy were available, but there was a trend towards superiority for CCBs plus ACE inhibitors or diuretics compared to other combinations. No studies examined the effect of antihypertensive therapy on morbidity or mortality outcomes.Conclusion: Evidence broadly supports current guidelines and provides a clear rationale for promoting CCBs as first-line agents and early initiation of combination therapy. However, there is a clear requirement for more evidence to provide a nuanced understanding of stroke and other cardiovascular disease prevention amongst diverse populations on the continent.

Integrated multi-month dispensing of antihypertensive and antiretroviral therapy to sustain hypertension and HIV control

“…These patients opted for alternative medications for hypertension but remained active in care at the HIV clinic. This prevalence (1.4%) of adverse drug events necessitating a drug change was lower than the frequency reported in literature of about 3-4% [ 20 ]. Two of the four patients that died from a cardiovascular disease related cause died during the period of interrupted hypertension treatment due to the Covid-19 national lockdown, and four of the eight deaths were not cardiovascular related.…”

“…However, the feasibility and effectiveness of integrating MMD of hypertension medications and ART among hypertensive PLHIV have not been studied in SSA, where monthly dispensing of hypertension medicine is the usual practice [ 19 , 20 ]. In this study, we determined treatment outcomes among hypertensive PLHIV who received integrated MMD of hypertension and HIV medicines at Uganda’s largest HIV clinic at baseline and after 12 months of MMD.…”

Pathophysiologically based antihypertensive pharmacotherapeutics rationality, efficacy and safety in Sub Saharan African Nations – A review

“…Thiazides were the most prescribed AHD class, followed by CCB, but CCB are the most efficacious antihypertensive monotherapeutic class [ 44 ]. Consistent with this, CCB as first-line drugs, or in combination with TD or ACEI, was recently reported to be most efficacious antihypertensive agents in a meta -analysis in Black Africans [ 96 ].…”

Amlodipine or Lisinopril in Combination with Bendroflumethiazide in Clinic Blood Pressure Control among Hypertensive Tanzanians with Moderate to Severe Hypertension: A Comparison Study

“…This study is among the few [15,20] to compare the efficacy of commonly prescribed antihypertensives in the sub Saharan Africa region and to the best of our knowledge, the first in Tanzania. As efforts continue to increase the performance to control BP, and within the context of many infectious and poverty-related diseases that demand priority, simple hypertension treatment protocols are highly needed in Tanzania and the sub Saharan Africa region.…”