Two Injections A Year For Blood Pressure? Lancet Review Signals Major Shift In Hypertension Care

Treatment for high blood pressure which has long depended on daily pills could soon move to just two injections a year, according to a new review in The Lancet that outlines late-stage therapies now in global trials.

The development, researchers say, could fundamentally change how hypertension is managed, particularly at a time when control rates remain alarmingly low despite decades of available medicines.

How The New Therapy Works

The review in The Lancet highlights emerging treatments that act upstream in the disease pathway rather than simply lowering numbers.

One of the most advanced candidates, Zilebesiran, being developed by Roche and Alnylam Pharmaceuticals, uses small interfering RNA (siRNA) technology to suppress the liver's production of angiotensinogen, a protein central to blood pressure regulation. By dampening this pathway, the drug can reduce blood pressure for up to six months after a single injection. It is currently in phase 3 trials following promising mid-stage results.

Clinical trials of investigational agents have shown that one subcutaneous injection can lower systolic blood pressure for up to six months. Mid-stage findings, some also reported in the New England Journal of Medicine, demonstrated meaningful and sustained reductions.

Another investigational therapy, Ziltivekimab from Novo Nordisk, targets inflammatory pathways increasingly linked to cardiovascular risk. Additional strategies are exploring more precise control of aldosterone, a hormone that regulates salt and water balance.

The review notes that poor adherence to daily medication remains one of the largest barriers to effective hypertension control globally. Long-acting injectables, researchers argue, could help bridge this gap if ongoing studies confirm safety and durability.

Is It Safe? What About Cost?

Early trials suggest a favourable safety profile, but researchers caution that hypertension is a lifelong condition and that these therapies remain under clinical evaluation and are not yet ready to replace standard treatment. Long-term cardiovascular outcome studies and large-scale safety data will be essential before widespread rollout.

Affordability could also shape accessibility. Long-acting injectables in other cardiovascular domains have entered the market at high price points, raising concerns about equitable access, particularly in low- and middle-income countries where hypertension rates are highest.

What Doctors Are Saying

Dr Amit Raj, Director at Plexus Cardiac Care, said the field may be approaching a structural shift in how hypertension is treated.

"These therapies are designed to act at the biological source of high blood pressure rather than repeatedly countering its effects," he told NDTV. "If longer-term data confirms current findings then twice-yearly dosing could soon become a practical reality and potentially lower the burden of heart attacks and strokes associated with uncontrolled hypertension."

Dr Raj explains that injectable treatment for hypertension has the potential to significantly improve real-world control rates by eliminating missed daily doses, which is one of the biggest barriers in hypertension management globally.

"This represents more than just a new drug, it signals the beginning of a precision cardiovascular era, where treatment is longer-acting, more predictable and designed around real-world patient behavior," he said.

Dr Nitish Naik, Senior Cardiologist at AIIMS Delhi, urged caution in interpreting the development as a breakthrough.

"I would not describe this as a gamechanger from a public health standpoint," he said. "The bigger challenge in hypertension control is access to affordable healthcare. Unless care is accessible and affordable, patients do not return for regular follow-ups, diagnosis remains delayed, and treatment continuity suffers."

He emphasised that strengthening primary care systems, expanding wellness centres and increasing the number of general physicians may have a far greater impact on blood pressure control than introducing high-cost therapies.

"These injectables may benefit a segment of patients, but to suggest they are the solution to uncontrolled hypertension globally would be premature," Dr Naik said. "Hypertension is a lifelong condition. If someone develops an adverse reaction months after receiving a long-acting drug, managing that becomes complex. Long-term safety data across diverse populations is essential."

He also noted that while conventional antihypertensive therapies have robust evidence showing reduction in heart attacks and strokes, similar long-term cardiovascular outcome data for these newer agents is still evolving.

"This is promising research and an important step forward," he added. "But it is the beginning of a journey, not a eureka moment."

Why Daily Pills May Fall Short

Current guidelines recommend combinations of oral drugs, including ACE inhibitors, angiotensin receptor blockers, calcium channel blockers and diuretics, to reach target blood pressure.

While effective in clinical settings, real-world challenges persist. Many patients simultaneously manage diabetes, obesity or cholesterol disorders, leading to multiple prescriptions. Missed doses, side effects and "pill fatigue" often undermine outcomes.

It is this adherence gap that long-acting injectable therapies aim to close.

A Global Crisis With Poor Control

Hypertension continues to be the leading cause of heart attacks, strokes and premature deaths worldwide. The World Health Organization defines it as blood pressure at or above 140/90 mm Hg. Normal levels are below 120/80 mm Hg.

Globally, an estimated 1.4 billion adults between 30 and 79 years live with the condition. Nearly 44 per cent do not know they have it. Among those diagnosed, fewer than one in four achieve adequate control.

India reflects the same trend. The 2023 ICMR-INDIAB study estimated that over 315 million Indians, which is more than a third of the population, have hypertension. National Family Health Survey-5 data further show that a significant proportion of diagnosed patients do not have their blood pressure under control.

Doctors point out that the issue is not the absence of medication, but inconsistent adherence, therapeutic inertia and long-term disengagement from care.

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