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The "Polypill" and Cardiovascular Disease

When it comes to treating cardiovascular disease, there are two conflicting and diametrically opposed philosophies out there. On the one hand, you have personalized medicine and the idea that treatment should be tailored to the specific risk profile of the individual patient. On the other hand, you have the polypill.

The idea of a polypill was first proposed nearly 20 years ago and the idea was a simple one. Make one pill that contained a baby aspirin, a cholesterol medication, and blood pressure pills. Rather than take four different medications, people could take a single pill once a day. The advantages in terms of convenience are obvious and patients are less likely to forget to take a single pill.

A recent study in the Lancet, tested the idea of a polypill in rural areas of Iran to determine whether it would be effective in preventing cardiovascular disease, heart failure and stroke. While previous studies have looked at the effectiveness of polypills before, most notably in places like India, the current Lancet study was significant in that it looked at whether a polypill could reduce hard clinical endpoints like heart attacks rather than than just looking to see if it reduced risk factors like blood pressure and cholesterol.

There are many aspects of a polypill strategy that are hard for people to contemplate. First off, a polypill strategy is designed to treat everyone in a population. This treat-everyone strategy is very different from the general strategy that most people are familiar where you get diagnosed with high blood pressure or cholesterol or diabetes and then take medications specifically for that. The polypill strategy is predicated on the idea that you would treat everyone in a population (or at least everyone over a certain age cutoff, the current study used age 50) regardless of their individual risk profile.

At first glance, you would suppose that treating everyone in a population would be very prohibitively expensive. But in actuality, the main advantage of a polypill strategy is its cost effectiveness. Firstly, the medications used in a polypill are generally common and inexpensive medications like aspirin, statins and routine blood pressure drugs. Depending on the formulation, a polypill can cost as little as 6 cents per day. Second, although treating everyone in a population sounds expensive you actually save money by not subjecting people to numerous blood tests and the doctor visits that these blood tests require.

Despite the understandable complaints that it is hard to get a doctor’s appointment when needed, we sometimes forget that we are relatively blessed to have access to such wide-ranging medical care. We forget that on large swaths of this planet, geography and economics conspire to make it difficult for many people to have access to the medical care we take for granted. In many low and middle-income countries, cardiovascular disease is very common and often untreated. A polypill strategy, if it could potentially treat the many people walking around with untreated high blood pressure or high cholesterol, could theoretically reduce heart disease risk by over 80%.

However, we will probably not see a polypill to treat cardiovascular disease in North America any time soon. We do use fixed dose combination pills to treat people with HIV and tuberculosis, but this is slightly different. With HIV and tuberculosis we are treating patients with a diagnosed and confirmed illness and simply replacing their 3 or 4 drug regimen with a single tablet for the purpose of convenience. When we speak of the polypill for cardiovascular disease we are discussing a wholesale shift in our philosophical approach to patient care.

Here in North America, we tailor our treatment to the individual. With a polypill, we are not treating patients, we are treating populations.


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