Still Playing Solo: Why GPs Won’t Drop Monotherapy

Key Takeaway: A qualitative study of 20 Australian general practitioners revealed that most are unaware of current international hypertension guidelines and continue to initiate treatment with a single medication, adhering to older, more flexible blood pressure targets. The findings point to a persistent gap between evidence-based recommendations and clinical practice—a gap that likely extends far beyond Australia.

A Playbook from 2016

Imagine walking into your doctor’s office with a blood pressure reading of 148/92 mmHg. Your physician reaches for a prescription pad and writes for a single agent: one pill, one mechanism of action, one modest goal. It seems like a reasonable approach. Except, it’s an approach that international hypertension authorities began moving away from years ago. While guidelines from organizations like the International Society of Hypertension now recommend a more aggressive start with combination therapy and stricter blood pressure targets, a new study reveals that many primary care physicians in Australia are still following an older, less effective script. And it’s almost certain this isn’t just an Australian problem.

What Did the Researchers Do?

This was a qualitative study, meaning researchers weren’t taking blood pressure measurements or counting pills. Instead, they conducted in-depth interviews with 20 Australian general practitioners (GPs) to understand how they think about, initiate, and manage hypertension treatment. The participants varied in age, experience, and clinical setting, offering a cross-section of real-world primary care practice. The interviews explored awareness of current guidelines, attitudes toward combination therapy, perceived barriers to blood pressure control, and comfort levels with newer treatment strategies^[1].

What Did They Find, and Why Does It Matter?

The results paint a concerning picture. The vast majority of interviewed GPs still adhered to the 2016 Australian hypertension guidelines. They initiated treatment with monotherapy—typically a single drug like an ACE inhibitor or a calcium channel blocker—and aimed for a blood pressure target below 140/90 mmHg. Few were aware that international guidelines now advocate for initial combination therapy using single-pill combinations (SPCs) and recommend tighter targets, often below 130/80 mmHg, for many patients.

Single-pill combinations, which combine two complementary antihypertensive drugs in one tablet, were rarely used as first-line therapy. The GPs perceived them as difficult to titrate, expressing concern about adjusting doses when two agents are locked into a single tablet. This concern, while superficially understandable, contradicts a growing body of evidence. A landmark meta-analysis published in The Lancet demonstrated that low-dose combination therapy achieves a much greater reduction in blood pressure than doubling the dose of a single agent and causes fewer side effects^[2].

Perhaps most troubling were the realities the GPs didn’t acknowledge. Therapeutic inertia—the well-documented failure to intensify treatment despite blood pressure remaining above target—was rarely identified as a problem by the participants themselves. Likewise, non-adherence was not seen as a major issue, even though studies show that about half of patients prescribed antihypertensives stop taking them within a year^[3]. Yet SPCs directly improve adherence by reducing the pill burden; taking one tablet instead of two or three significantly increases the likelihood that patients will stick with their treatment^[4].

There was one promising finding: younger GPs and those with academic affiliations—links to universities or research institutions—were more open to lower blood pressure targets and the initial use of SPCs. This suggests that the medical education pipeline is slowly catching up, but the majority of practicing clinicians remain anchored to outdated paradigms.

The Mechanism: Why Starting Strong Matters

To understand why this matters physiologically, consider what happens when blood pressure remains high. Hypertension doesn’t damage the body in one dramatic event. It works through relentless mechanical stress on arterial walls over years. The high pressure accelerates atherosclerosis, thickens the heart’s left ventricle, damages the delicate filtration units of the kidneys, and remodels the small blood vessels in the brain and retina^[5]. Every month a patient spends above their optimal target is a month of cumulative organ damage.

Monotherapy, by definition, addresses only one of the multiple physiological pathways that sustain high blood pressure—such as the renin-angiotensin system, peripheral vascular resistance, or fluid volume. The human body is remarkably adept at compensating. Block one pathway, and counter-regulatory mechanisms kick in, blunting the drug’s effect. Combination therapy disrupts this compensation by intervening in two pathways simultaneously, which is precisely why two drugs at a low dose outperform one drug at a high dose^[2]. Starting with combination therapy gets patients to their target faster, and time-to-target is increasingly recognized as a critical determinant of long-term cardiovascular outcomes^[6].

Notable Limitations

This was a qualitative study of 20 GPs in a single country. It was designed to explore attitudes and perceptions, not to measure clinical outcomes or quantify the prevalence of guideline non-adherence across an entire healthcare system. While diverse, the sample cannot be considered statistically representative of all Australian GPs, let alone physicians worldwide. Qualitative research generates hypotheses and illuminates patterns; it does not provide definitive, population-level conclusions.

The Verdict: What This Means for Tomorrow’s Patients

If you are being treated for high blood pressure with a single medication and your readings remain above 130/80 mmHg, this study suggests you may be caught in the same gap between evidence and practice. The research makes a compelling case that national guideline-writing bodies need to update their recommendations more frequently and that continuing medical education must do a better job of reaching the clinicians who see patients every day, not just the academics who attend international conferences. For patients, the actionable message is simple: ask your physician what your blood pressure target is, whether combination therapy might be appropriate, and if a single-pill combination could simplify your regimen. The evidence increasingly supports starting strong and getting to the goal quickly. The cost of waiting—measured in silent, cumulative damage to the heart, kidneys, and brain—is too high to accept an outdated playbook.

Scientific Sources

1. Gnanenthiran SR, et al. Implementation of Clinical Hypertension Guidelines and Single Pill Combinations: A Qualitative Study in Australian General Practice. American journal of hypertension. 2026. PubMed: https://pubmed.ncbi.nlm.nih.gov/42693929/
2. Wald DS, et al. Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials. Am J Med. 2009. DOI: 10.1016/j.amjmed.2008.09.038
3. Vrijens B, et al. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008. DOI: 10.1136/bmj.39553.670231.25
4. Gupta AK, et al. Compliance, safety, and effectiveness of fixed-dose combinations of antihypertensive agents: a meta-analysis. Hypertension. 2010. DOI: 10.1161/HYPERTENSIONAHA.109.139816
5. Renna NF, et al. Pathophysiology of vascular remodeling in hypertension. Int J Hypertens. 2013. DOI: 10.1155/2013/808353
6. Thomopoulos C, et al. Effects of blood pressure lowering treatment in hypertension: head-to-head comparisons of various classes of antihypertensive drugs. J Hypertens. 2015. DOI: 10.1097/HJH.0000000000000614