To twofer or not to twofer

Abstract

The two-for-one therapeutic concept or, namely, to treat two conditions with one drug, is attractive for a variety of reasons; among these are a reduction in adverse effects, the number of pills, and cost. Physicians and patients, therefore, like the “twofer” and use it whenever possible. Unfortunately, the concept of the twofer has never been vigorously tested. Ironclad trials have shown that beta-blockers confer secondary cardioprotection in patients who have suffered an acute MI [26]. However, beta-blockers have no primary cardioprotective effect in hypertension, and there are no studies showing that the reduction of BP by beta-blockers confers any additional benefit in the post-MI patient with hypertension, as would be expected from the fact that two risk factors are modified by one and the same drug. In the post-MI patient, it seems more logical to use a beta-blocker for secondary cardioprotection and to treat hypertension separately by adding another drug class that has been shown to have outcome benefits in hypertension, such as a diuretic, calcium antagonist, or ACE inhibitor. The twofer, however, is perfectly acceptable in the same situation for the ACE inhibitor. ACE inhibitors have well-documented benefits in the post-MI patient (secondary prevention) [27,28], and the treatment of hypertension with an ACE inhibitor has been shown to reduce morbidity and mortality (primary prevention).