25 May 2011 Polypillomania
Drug and Therapeutics Bulletin
The Independent Review of Medical Treatment
Vol 49 | No 2 | February 2011
Ever since the concept of the ‘polypill’ was introduced,1,2 it has maintained an almost magical hold over the lay press and many healthcare professionals. Entering the term into a search engine gives a rich yield of results, and the polypill has a presence on social media favourites including Twitter, Facebook and Wikipedia. With the announcement of another trial last month, the polypill is back in the news.3 Does it really deserve much hype?
The argument proposed in favour of a polypill is seductive — a single pill to reduce the likelihood of cardiovascular disease. Those in favour suggest that the combination of several evidence-based drugs would allow for a one-size-fits-all product that should improve adherence as well as providing a low-cost intervention that would help target those at highest risk in developing countries. However, the reality turns out to be not so straightforward, not least because we seem to have moved into a world of poly-polypills.
Existing trials (published and ongoing) of the various polypills target different populations, differ in the types and doses of drugs they include and measure different outcomes. Patients included in such studies have ranged from those who would not currently be considered eligible for antihypertensive or lipid-lowering treatment to those with established cardiovascular disease. Polypill formulations have generally contained simvastatin (at a dose no greater than 40mg), aspirin, an angiotensin converting enzyme inhibitor and a beta-blocker or a thiazide diuretic. The trials’ focus has typically been on adherence, and impact on blood pressure and cholesterol. Comparators have been placebo, usual care/standard practice, or some of the individual components of the polypill. The latest trial to be announced (a 24-week double-blind placebo cross-over study) will assess yet another formulation (simvastatin 40mg, losartan 25mg, amlodipine 2.5mg, hydrochlorothiazide 12.5mg) given to people aged over 50 years, again focusing on the effect on blood pressure and cholesterol rather than the impact on mortality and morbidity.3
With such a range of formulations and possible indications, it would seem that the original concept of a simple solution to a common problem has mutated into testing an increasingly complex range of potential products for multiple patient populations. And even when the data from all these studies are available, they won’t answer a fundamental question: how well the various polypills truly compare with established non-polypill multidrug regimens in terms of the long-term outcomes that really matter to patients. Not that this seems to be a primary concern to some proponents of polypills, who argue that short-term effects on markers such as cholesterol and blood pressure are evidence that the product will be as effective as the individual components taken separately in preventing cardiovascular events in the long term.
As things stand, it’s hard to see justification for the largely uncritical coverage that is given to the polypill, an idea in danger of becoming a solution that’s desperately seeking a problem, rather than the other way round.
- Wald NJ, Law MR. A strategy to reduce cardiovasculer disease by more than 80%. bmj.com 2003; 326: 1419.
- Yusuf S. Iwo decades of progress in preventing cerdiovascular disease. Lancet 2002; 360: 2—3.
- Queen Mary University of London Media Centre, 201 1 . A pill a day could keep heart attacks and strokes at bay [online]. Available: http://www.qmul.ac.uk/media/news/items/smd/41 534.html [Accessed 21 January 2011].