The Polypill – RGH E-Bulletin

Heart disease is the leading cause of death worldwide. What if there was one tablet that could reduce heart disease by 80%. Too good to be true?

The concept of the “polypill” was first published in 2003 when Wald and Law conducted a theoretical projection analysis of a single pill which contained six drugs. That polypill comprised of three anti-hypertensives at half dose (thiazide, beta blocker and ACE inhibitor), plus aspirin, a statin and folic acid. The predicted benefit from this analysis was an 88% reduction in ischaemic heart disease events and an 80% reduction in stroke.

A year earlier Yusuf had proposed a similar combination but without the catchy name: the predicted benefit of this four-drug combination was a 75% reduction of cumulative risk of CVD events when used for secondary prevention.

The complete RGH E-Bulletin can be downloaded here

Compare this article to the Kanyini Vascular Collaboration which also includes a polypill trial.

The Bulletin is a joint initiative of the Patient Services Section and the Drug and Therapeutics Information Service of the Pharmacy Department, Repatriation General Hospital, Daw Park, South Australia. The RGH Pharmacy E-Bulletin is distributed in electronic format on a weekly basis, and aims to present concise, factual information on issues of current interest in therapeutics, drug safety and cost-effective use of medications.

Editor: Assoc. Prof. Chris Alderman, University of South Australia – Director of Pharmacy, RGH © Pharmacy Department, Repatriation General Hospital, Daw Park, South Australia 5041

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Kanyini Vascular Collaboration

Australia’s Indigenous population have a much higher incidence of heart disease, diabetes and kidney disease than other Australians and are less likely to receive treatment for these conditions. I have discussed this recently.

The Kanyini Vascular Collaboration is a research project to try and identify barriers to best practice chronic disease management in Aboriginal and Torres Strait Islander people to improve their health. I have written extensively about this research trial some time ago and thought it time for a quick update.

The polypill trial is about to enter final planning when we gather in Sydney next week.

There has been a little bit of work published with more on the way. An article has been published in the Canadian Medical Association Journal titled “Addressing inequities in access to quality health care for indigenous people” looking at the inequities and barriers in both a practical and historical context with some comparisons to the problems in delivering a service to the Canadian Aborigine population.

The Heart, Lung and Circulation (Volume 17, Supplement 3, 2008, Page S157) has an article titled “The Identification and Management of Vascular Diseases and Their Risk Factors in Eight Indigenous Primary Health Care Services—The Results of the Kanyini Vascular Collaboration Audit study“. Unfortunately, unless you have access through a library you have to pay for the article.

The Kanyini Vascular Collaboration also produces it’s own newsletter which can be downloaded here (678kb pdf).

I will keep you up to date as the trial progresses.

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Indigenous Health Research and the Polypill

Way back in 2003 there was a very contentious article published in the BMJ, “A strategy to reduce cardiovascular disease by more than 80%” along with an editorial “A cure for cardiovascular disease?” The proposed polypill had six ingredients and the editorial claimed that the “combination treatment has enormous potential, especially in developing countries.” It has since been patented.

Since then it has been talked about a lot including an editorial in the Australian Prescriber in 2005 asking whether a polypill would be friend or foe and would a “one size fits all” approach be beneficial to patients. The use of a polypill as primary prevention from cardiovascular death was contentious.

Moving along to the present and a number of polypill trials are commencing or are planned, including in India, and a six country trial including England, NewZealand and Australia.This trial will include people who have a raised risk of heart attack or stroke, but are not on any medication and have no other related health issues.

Several years ago in a discussion with a doctor it was asked why we don’t have a polypill made. With less tablets for our patients to take perhaps it would improve adherence. I could see a lot of problems, particularly testing for stability if we were going to have large amounts produced. It would also be very costly. I asked around and found the Kanyini Vascular Collaboration was in the planning stages. We have been involved with it ever since.

The S100 supply of medications to remote indigenous communities has certainly improved access to drugs but indigenous people experience a greater burden of all disease including heart disease, diabetes and kidney disease than the non-Indigenous population. The study is looking to find out why this occurs and how to improve it.

The study is funded by the National Health and Medical Research Council (NHMRC) and is being run by The Baker Heart Research Institute, Alice Springs and The George Institute for International Health, Sydney.

Aboriginal health services around the country are involved, including city, rural and remote. A map with the participating services can be found here. Ngaanyatjarra Health Service is the only aboriginal health service in Western Australia participating in the trial.

It consists of many parts, some will run concurrently, others staged, over a number of years.

The aim of the Kanyini Vascular Audit

    is to quantify the magnitude of evidence-practice gaps in the identification and management of vascular risk among Aboriginal and Torres Strait Islander people.

There is a Qualitative Study involving:

    patients at high cardiovascular disease risk, their families and community members, professional health care providers, managers and policy makers in Aboriginal and Torres Strait Islander health to give us greater understanding of the barriers faced and the ways our indigenous population can access best practice chronic disease care and prevention.

There will also be two studies trialling different interventions that will be directed by the results of the research that is currently occurring.

I started off writing about a polypill. There is also a polypill component to this research that we hope to commence this year. There will be two different versions. Other treatments can be added as required. They contain an angiotensin converting enzyme inhibitor, statin, aspirin, Beta blocker or thiazide diuretic.

The logistics of this will be interesting for my mob as they move between three states and may be evacuated to three cities by the RFDS. However I am very excited that the health problems of indigenous Australia have started to be looked at seriously at a policy and practical level rather than just as statistics to bandy around.

“Kanyini” is a word in use in several central Australian aboriginal languages.It is a great word that can be translated as “to have, to hold and to care”.

From the website:

    “Kanyini is a verb which reflects a commitment, a full engagement; vitalising again and again all that went before and all that will go after”*

    It represents one of the four foundations of Aboriginal life in Central Australia: Tjukurpa (Law, Dreaming); Walytja (Family); Ngurra (Land, Country) and Kanyini. In essence, Kanyini describes the principle and primacy of caring for others – an obligation to nurture, protect and care for other people, family, country and the law.

There is a documentary titled Kanyini. The story guide may be of interest.

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