Treatment Strategies to Control Blood Pressure in People With Hypertension in Tanzania and Lesotho: A Randomized Clinical Trial.

Summary

In 1,268 adults with untreated hypertension in Lesotho and Tanzania, initiating low-dose dual therapy (amlodipine 5 mg + losartan 50 mg) was noninferior to stepped monotherapy for achieving target blood pressure at 12 weeks. Low-dose triple therapy did not significantly outperform monotherapy, and wide confidence intervals suggest uncertainty regarding small effect sizes.

Key Findings

• At 12 weeks, 56% (2-pill) vs 51% (stepped monotherapy) reached BP targets; noninferiority met (aOR 1.18; 95% CI 0.87–1.61).
• Low-dose triple therapy: 57% achieved target vs 49% with stepped monotherapy; not statistically superior (aOR 1.28; 95% CI 0.91–1.79).
• Findings support WHO guidance to start dual therapy and highlight uncertainty (wide CIs) regarding added benefits of triple therapy.

Clinical Implications

Initiating low-dose dual therapy is a viable and noninferior approach for first-line treatment in uncomplicated hypertension in resource-limited settings; triple therapy may be reserved until further evidence clarifies benefits. Implementation should consider medication access and follow-up capacity.

Limitations

• Open-label design and short 12-week follow-up limit detection of long-term differences.
• Wide confidence intervals preclude ruling out clinically meaningful effects of additional pills.

Future Directions

Longer-term, larger-scale trials in diverse LMIC settings should evaluate sustained BP control, adherence, safety, and hard outcomes, and assess cost-effectiveness of dual vs triple therapy initiation.