Choice of angiotensin receptor blocker in moderate hypertension. A UK-based cost–benefit comparison of olmesartan- and candesartan-based regimens

Figures & data

Table 1.  Price range and market share for ARBs (PPA: England, October–December 2010)5,6.

	Prescriptions per month/% share	Price range (standard antihypertensive dose range)	Price range (with thiazide)	Price range (with CCB)
All ARBs	1,387,154	–	–	–
Candesartan	35.3%	£9.89–16.32	£10.78–17.38*	£10.94–17.51^†
Losartan (generic)	24.0%	£1.54–1.74	£3.49–16.18	£2.59–2.93^†
Irbesartan	17.0%	£11.84–15.93	£11.84–15.93	£12.89–17.12^†
Valsartan	11.2%	£13.97–20.23	£13.97–21.29*	£15.02–21.42^†
Olmesartan	6.3%	£10.95–17.50	£12.95–17.50	£16.95 (all doses)
Telmisartan	4.9%	£12.50–17.00	£12.50–17.00	£13.55–18.19^†
Eprosartan	1.3%	£14.31–15.77	£15.20–16.83*	£15.36–16.96^†

*Where a standard combination product is not available the price of generic bendroflumethiazide 2.5–5 mg (£0.89–1.06) is added to the standard dose range.

^†Where a standard combination product is not available the price of generic amlodipine 5–10 mg (£1.05–1.19) is added to the standard dose range.

Figure 1.  Placebo corrected mean effect of ARBs on diastolic blood pressure (reproduced with permission from Zannad et al.7).

Figure 2.  Schematic representation of cost–benefit model.

Figure 3.  Treatment algorithm.  ARB step 1: Olmesartan 10 mg/candesartan 8 mg  ARB step 2: Olmesartan 20 mg/candesartan 16 mg  ARB step 3: Olmesartan 40 mg/candesartan 32 mg  Thiazide step 1: Hydrochlorothiazide 12.5 mg/bendroflumethiazide 2.5 mg  Thiazide step 2: Hydrochlorothiazide 25 mg/bendroflumethiazide 5 mg  CCB step 1: Amlodipine 5 mg  CCB step 2: Amlodipine 10 mg.

Table 2.  Estimates of dose-specific BP lowering efficacy8–10,12.

	Systolic BP		Diastolic BP
	Mean reduction (mmHg)	95% CI	Mean reduction (mmHg)	95% CI (mmHg)
Olmesartan 10 mg	10.7	9.0–12.4	11.3	9.6–13.0
Olmesartan 20 mg	15.5	13.8–17.2	13.8	12.1–15.5
Olmesartan 20 mg + HCTZ 12.5 mg	20.1	18.5–21.7	16.4	14.8–18.0
Olmesartan 20 mg + HCTZ 25 mg	27.1	25.1–29.1	20.0	18.0–22.0
Olmesartan 20 mg + Aml 5 mg	25.3	23.6–27.0	19.0	17.3–20.7
Olmesartan 20 mg + Aml 10 mg	30.9	28.5–33.2	21.9	19.5–24.3
Olmesartan 40 mg + HCTZ 25 mg  + Aml 10 mg	33.2	30.8–35.5	26.8	24.4–29.2
Candesartan 8 mg	12.2	11.2–13.2	9.2	8.4–10.0
Candesartan 16 mg	13.6	12.7–14.5	10.4	9.7–11.1
Candesartan 16 mg + BFTZ 2.5 mg	19.3	18.4–20.2	13.0	12.3–13.7
Candesartan 16 mg + BFTZ 5 mg	22.2	21.2–23.2	14.7	13.9–15.5
Candesartan 32 mg + Aml 5 mg	29.8	28.8–30.8	15.6	14.8–16.4
Candesartan 16 mg + Aml 10 mg			18.5	17.7–19.3
Candesartan 16 mg + BFTZ 5 mg  + Aml 10 mg			20.7	19.9–21.5

HCTZ, hydrochlorothiazide; Aml, amlodipine; BFTZ, bendroflumethiazide.

Figure 4.  Numbers of treatments required to reach targets: broken down by ARB and target used.

Table 3.  Distribution of patients across titration levels.

	Systolic target: 150 mmHg		Systolic target: 140 mmHg		Diastolic target: 90 mmHg
	Olmesartan	Candesartan	Olmesartan	Candesartan	Olmesartan	Candesartan
Level 1: low-dose ARB	12.4%	16.5%	0.8%	1.3%	18.3%	7.5%
Level 2: mid-dose ARB	16.4%	4.7%	2.7%	0.7%	20.3%	5.2%
Level 3: mid-dose ARB  + low-dose Thiazide or Aml	33.7%	35.3%	15.8%	12.7%	34.9%	30.7%
Level 4: mid-dose ARB  + high-dose Thiazide or Aml	23.5%	17.4%	25.7%	16.0%	18.4%	20.5%
Level 5: high-dose ARB  + Thiazide + Aml	8.8%	15.1%	20.4%	18.3%	7.8%	28.3%
Target not achieved	5.1%	11.0%	34.5%	51.0%	0.2%	7.8%
At target on one drug	28.8%	21.2%	3.5%	2.0%	38.6%	12.7%
At target on two drugs	57.2%	52.7%	41.5%	28.7%	53.3%	51.2%
Requires more than two drugs	13.9%	26.1%	54.9%	69.3%	8.0%	36.1%

Table 4.  Mean estimated 12-month costs per patient + mean cost per patient to target.

	Systolic target: 150 mmHg		Systolic target: 140 mmHg		Diastolic target: 90 mmHg
	Olmesartan	Candesartan	Olmesartan	Candesartan	Olmesartan	Candesartan
Total cost (year 1)	£162.68	£168.99	£199.41	£216.75	£155.73	£174.30
Ongoing annual cost	£169.97	£182.64	£227.58	£257.14	£159.60	£188.74
Mean cost per patient to target	£171.36	£189.91	£304.50	£441.96	£156.11	£189.13

Figure 5.  Mean cost per patient to target broken down by ARB and target used.

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