Why Prescribe Single Pill Combinations? (Toub, 10/14/2026)

A recording of this presentation is available HERE.

Thanks so much to Dr. Danny Toub, core faculty, family doctor, and HIV specialist, who gave an awesome talk on Single Pill Combinations (SPCs). The recorded talk is available above. Dr. Toub started off by saying he wasn't going to talk about HIV meds-- and he didn't!-- instead he gave a convincing argument why we should DEFINITELY be considering SPCs for patients with hypertension, at the very least.

Single Pill Combinations (SPCs) or Single Tablet Regimens (STRs) or Fixed Dose Combinations (FDC) are, by definition, medications that contain two or more more pharmaceutical ingredients within a specified ratio, combined in one form, in the form of a tablet, capsule or injection. SPCs go way back to the 1950s (hydralazine and reserpine) and 1960s (birth control pills-- estrogen and progesterone).

There are a fair number of SPCs on the Medi-Cal formulary (see image):

including a fair number of medications to treat/prevent infectious disease (see image):

SPCs have many advantages, including 1) prevention development of drug resistance (e.g. h pylori regimens) 2) improved efficacy 3) improved adherence (only 50% of patients take medications as prescribed) in addition to 4) fewer pills, 5) less frequent dosing. Some SPCs can even deter misuse (think of Suboxone, which contains both naloxone and buprenorphine).

AND, as Dr. Toub pointed out, another advantage is SYNERGY-- that is, the unified whole is even better than the sum of all the parts. 

With specific regard to hypertension, we know that only 25% of US adults with hypertension are at goal BP, less than half of patients with hypertension who are on meds are at goal, about 40% of US adults with hypertension are still only on a single medication, whereas about 75% of patients NEED a second agent to achieve BP control <140/90.

The AHA released a 2026 statement on the use of SPCs for hypertension, specifically: saying that the use of SPCs is preferred OVER stepped care (i.e. stop adding one med at a time, start out with two!)

https://www.ahajournals.org/doi/epub/10.1161/HYP.0000000000000258

The table below comes from a 2025 Lancet article summarizing how much each single agent decreases blood pressure:

https://pubmed.ncbi.nlm.nih.gov/40885583/

A 2009 Meta-analysis from the American Journal of Medicine, with over 11,000 patients combining 42 trials, found that adding a second agent had 5x the blood pressure effect as doubling the first agent!! It appears that the greatest bang for your buck (i.e. the most potent BP effect) comes from combing calcium channel blockers (CCBs) and angiotensin receptor blockers (ARBs). This combo reduced systolic BP by 19mmHg

AND, it gets even better: combining meds into a SPCs ironically seems to result in fewer adverse effects. For example, monotherapy with CCB is known to cause peripheral edema, but combining with an ARB seems to offset that side effect. In fact, in another Metanalysis from JAMA published in May 2026, the combination of CCB+ARB had the best profile, but even a triple combo (ARB/TZ/CCB) had better side effect profile than placebo. 

While some SPCs (especially newer branded ones) wind up being more costly, some actually cost less than the combination of separate medications. 

Santa Rosa Community Health (SRCH) has a Hypertension Guidelines that are taken from the Kaiser Hypertension Guidelines, generally using SPC that contains HCTZ+ lisinopril. Goal is to minimize pill burden AND get BP under control quickly with more convenience and less copays.

To be clear, SPCs are not without some disadvantages. They can be more costly. Some are gimmicks by pharma to sell "new drugs" with new names. Some combinations contain more medications than a patient actually needs (have you ever seen that cream from Mexico that combines topical steroid with anti-fungal AND anti-bacterial cream?). They can feel inflexible, lead to adverse effects and/or drug-drug interactions, and it can create a situation when a patient does have a side effect where it is very difficult to determine which agent is the culprit.

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What about for other conditions?

Dr. Toub was also encouraging us to consider SPCs for Cardiovascular Kidney Metabolic Syndrome (CKM). There are multiple SCPs that target these diseases (see image) and considering the number of medications and risks of morbidity/mortality, it is reasonable to think about pill burden at the very least. While there are no studies yet confirming improved outcomes with SCPs for CKM, initial combo treatment may be considered. 

In summary, SPCs are already widely accepted for many conditions, multiple guidelines recommend SCPs for Hypertension management, and they likely lead to better adherence, safer, more effective, and yet still under-used. Get to know your Medi-Cal formulary SCPs and go out and heal!

Understanding Hospice Care (Saeed, 9/30/26)

A recording of this presentation is available HERE.