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Overcoming the challenge of blood pressure control
in prediabetic and diabetic patients: PICASSO T2D Study
Efficacy and tolerability of fixed dose combination perindopril/indapamide
in type 2 diabetes
Background and objective of the study
The “bad companions”
make blood pressure
control challenging
Hypertension and type 2 diabetes deteriorate the vascular
environment and lead to micro- and macrovascular disease
Epidemiologic data from key studies (NHANES and I-SEARCH)
highlight the need for improving treatment strategies
•
•
Diabetic patients are more likely to be treated with antihypertensive drugs
However, they were 53% less likely to reach control than non diabetic patients
Recent guidelines
recommend to use
combinations
For diabetic hypertensive patients, European guidelines
(ESH/ESC 2013) recommend the use of combination therapy,
especially including RAAS inhibitors
Perindopril/indapamide is thus well suited for the treatment
of diabetic patients
Objective of the study
The objective of PICASSO T2D study is to assess the efficacy
and the tolerability of a fixed-dose combination of perindopril
and indapamide in lowering blood pressure
Ferrannini E, Cushman WC. Diabetes and hypertension: the bad companions. Lancet. 2012;380:601-10 / United States 2010 National Health and Nutrition
Examination Survey / International Survey Evaluating Microalbuminuria Routinely by Cardiologists in Patients with Hypertension / ESH-ESC 2013 Guidelines
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Methodology involved a retrospective analysis of a subgroup
of patients of PICASSO study
PICASSO study was a 3-month observational study conducted on 9 257 uncontrolled
hypertensive patients
Data of a subgroup of 2 762 patients with type 2 diabetes (T2D, N=1 887) or prediabetes
(N=875) were retrospectively analyzed
Patient
profile
Treatment
and
follow-up
Endpoints
Patients with hypertension as defined by 2007 ESC/ESH guidelines, with systolic blood pressure
(SBP)/diastolic blood pressure (DBP) <130/80 mm Hg
Blood pressure targets for patients with prediabetes are defined as <140/90 mm Hg
Patients with T2D were reported on case files, prediabetic patients were defined as patients with
a fasting blood glucose 5.6-6.9 mmol/L or with a positive oral glucose tolerance test
Patients received a fixed-dose combination of perindopril/indapamide 10mg/2.5mg for 3 months
Additional antihypertensive agents were allowed to be maintained or added according to the
doctor’s appreciation
Patients were measured at baseline, after one month and after 3 months of treatment
Office and ambulatory blood pressure (SBP/DBP)
Laboratory parameters to assess tolerance (fasting plasma glucose, serum total cholesterol, HDLC, LDL-C, triglycerides, potassium, creatinine and uric acid), at baseline and at 3 months
Farsang C, on behalf of the PICASSO investigators. Blood Press. 2013;22 Suppl 1:3-10 / ESH-ESC 2007 guidelines
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Results for office blood pressure
Mean office SBP/DBP change over three months
Changes from baseline to 3 months were statistically
significant (-26.9±14.8/-12.7±9.8 mm Hg; p <0.001)
After 3 months of treatment, blood pressure control was
reached in 69% of patients
Significant reductions were achieved regardless of the
severity of hypertension at inclusion
Mean office SBP/DBP change
according to previous other treatments
Mean office SBP/DBP decreased significantly regardless
of previous other treatments
In particular, office blood pressure decreased
significantly in patients previously treated by a RAAS
inhibitor±HCTZ (n = 1991), from 159.5±14.7/92.5±9.7 to
132.3±9.8/80.0±6.3 mm Hg (p <0.001)
The decrease in office blood pressure was similar for
patients previously on ACE inhibitors±HCTZ or on
ARB±HCTZ (both p <0.001)
Farsang C, on behalf of the PICASSO investigators. Blood Press. 2013;22 Suppl 1:3-10
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Results for ambulatory blood pressure
93 patients were followed up through ambulatory blood pressure monitoring system
Ambulatory SBP/DBP change after three months
Ambulatory SBP/DBP change after three months
and compared with other previous treatments
Mean day-time, night-time, and 24-hour BP as well as
In patients previously treated with ACE inhibitor±HCTZ
mean 24-hour pulse pressure, mean arterial pressure,
and mean 24-hour heart rate decreased significantly
over 3 months of treatment (p <0.001)
(n = 67) or ARB±HCTZ (n = 10), mean 24-hour blood
pressure decreased by 23.4±13.9/11.5±9.7 mm Hg and
22.3±8.7/10.4±13.2 mm Hg, respectively (p <0.001)
Farsang C, on behalf of the PICASSO investigators. Blood Press. 2013;22 Suppl 1:3-10
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Results for tolerability
Metabolic parameters change after three months of treatment with fixed dose combination of Perindopril/Indapamide
Metabolic markers were measured according to doctors’ willingness
Significant reductions of total cholesterol, LDL-C, glucose and triglycerides were measured after three months
Treatment was overall well tolerated, with 36 cases of drug-related adverse events reported, including
• Ankle edema (N=11 patients, 0.4% of patients)
• Dizziness (N=7 patients, 0.3% of patients)
• Cough (N=6 patients, 0.2% of patients)
• Seven serious adverse events were reported, none of which related to the study
Farsang C, on behalf of the PICASSO investigators. Blood Press. 2013;22 Suppl 1:3-10
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Conclusion
Key elements
Significant results relevant
to real life practice
Significant results with
long-term impact to be
further assessed
Results in line with
guidelines
PICASSO T2D study sticks to the challenges of daily medical practice
(uncontrolled hypertension in diabetic or prediabetic patients, despite
treatment)
BP was significantly reduced after three months of treatment
The treatment was well tolerated and improved laboratory parameters
Ambulatory SBP, BP variability and pulse pressure are predictors of
cardiovascular risk
In addition, BP variability through the day is impacting organ damage
Thus, a long-term study would be interesting to assess the impact of
perindopril/indapamide on organ damage and cardiovascular risk
For diabetic patients, treatment with ACE inhibitors is recommended for
their cardioprotective and nephroprotective effects
This recommendation has been confirmed in a recent analysis (CMAJ 2013)
In addition, the British Society of Hypertension has recently recommended
the use of indapamide or chlortalidone rather than HCTZ
Farsang C, on behalf of the PICASSO investigators. Blood Press. 2013;22 Suppl 1:3-10 / Lv J, Ehteshami P, Sarnak MJ, et al. CMAJ 2013.
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