Comparing Telmisartan Amlodipine FDC vs. Telmisartan Cilnidipine FDC in Indian Hypertensive Patients: Latest START RENAL 2026 Update

A recently published study has shown that the fixed-dose combination (FDC) of telmisartan-amlodipine showed significantly better blood pressure (BP) reduction compared to telmisartan-cilnidipine FDC in Indian patients with hypertension and renal impairment, while maintaining comparable renal outcomes.

These findings were published in the April 2026 issue of International Journal of Nephrology and Renovascular Disease by Dr Uday Jadhav, Dr Santanu Guha and colleagues.

Hypertension remains a major contributor to chronic kidney disease (CKD) progression and hypertensive nephropathy, a condition characterized by structural and functional kidney damage caused by persistent elevation in blood pressure. In India, the growing burden of hypertension, diabetes, obesity, and sedentary lifestyles is increasing the number of patients at risk of renal complications.

The Kidney Disease: Improving Global Outcomes (KDIGO) 2021 Practice Guidelines recommend renin-angiotensin system (RAS) inhibitors as first-line therapy, with the addition of a calcium channel blocker (CCB) if target BP is not achieved through monotherapy.

Telmisartan is widely used because of its established reno-protective benefits, but many patients require an additional antihypertensive agent for better BP control. Although both amlodipine and cilnidipine are recognized for managing hypertension with renal dysfunction, direct comparative studies remain limited. This study aimed to address this gap by evaluating the efficacy and safety of both telmisartan-amlodipine (TA) vs. telmisartan-cilnidipine (TC) fixed-dose combinations (FDCs) in patients with hypertension and renal impairment.

Study Overview

START Renal was an open-label, randomized, parallel-arm, post-marketing trial conducted across six centres in India. The study included patients aged 18 to 75 years with hypertension, defined as systolic blood pressure/diastolic blood pressure ≥130/80 mmHg and <180/110 mmHg, along with renal impairment defined as estimated glomerular filtration rate (eGFR) of 60–90 mL/min/1.73 m² and urine albumin-creatinine ratio (UACR) of 30–600 mg/g.

A total of 188 participants were randomized in a 1:1 ratio to receive either telmisartan 40/80 mg plus amlodipine 5 mg (TA) or telmisartan 40/80 mg plus cilnidipine 10 mg (TC) once daily for 12 months. Follow-up visits were conducted at 3, 6, 9, and 12 months.

The primary endpoint was change in UACR (Urine Albumin-Creatinine Ratio) from baseline to 12 months. Secondary endpoints included changes in eGFR, serum creatinine, serum uric acid, office SBP & DBP, and safety outcomes.

The key results from the study include:

Greater SBP Reduction with Telmisartan-Amlodipine

• Both treatment groups demonstrated significant reductions in blood pressure throughout the study duration. However, researchers found that patients receiving telmisartan-amlodipine achieved significantly greater reductions in systolic blood pressure at later follow-up visits.
• At 9 months, SBP declined by 20.74 ± 12.75 mmHg in the telmisartan-amlodipine group compared to 16.9 ± 13.66 mmHg (p=0.0430) in the telmisartan-cilnidipine group.
• At 12 months, the difference remained significant, with SBP reducing by 25.4 ± 14.25 mmHg in the telmisartan-amlodipine group versus 20.6 ± 10.94 mmHg (p=0.0397) in the telmisartan-cilnidipine group.
• Diastolic blood pressure reductions remained comparable between both groups throughout the study period.

Diabetic Subgroup Also Showed Better SBP Reduction with Telmisartan-Amlodipine

Safety Outcomes

• Both TA and TC treatment combinations were well tolerated during the study period. A total of 17 drug-related adverse events were reported, with no serious adverse events observed. All affected patients recovered completely.

Why Better SBP Control Matters in Renal Patients?

Both systolic and diastolic blood pressure are important predictors of chronic kidney disease (CKD) progression. Among these, SBP has been shown to be a stronger predictor of renal outcomes than DBP, particularly in patients with CKD secondary to type 2 diabetes. Therefore, comparison of SBP between treatment groups is essential to evaluate its impact on renal outcomes and to assess the therapeutic effectiveness of interventions aimed at mitigating kidney damage.

One of the leading contributors Dr Uday Jadhav, from Department of Cardiology and Cardiac CT, MGM New Bombay Hospital, Mumbai,(HCP name and credential client to double check and confirm please) said, “More than 33% of Indians with systemic hypertension develop microalbuminuria, which can progress to hypertensive nephropathy and eventually end-stage kidney disease. Managing these patients remain particularly challenging, as clinicians need therapies that deliver effective blood pressure control while preserving kidney function. Although telmisartan-based combinations are widely used in routine practice, there has been limited comparative Indian data on telmisartan amlodipine with telmisartan cilnidipine in patients with both hypertension and renal impairment. This study was important because it addresses that evidence gap and provides practical guidance for Indian clinicians managing high-risk patients.”

This study's findings concluded that the telmisartan-amlodipine FDC showed better blood pressure reduction while maintaining renal safety compared to telmisartan cilnidipine FDC, making it a potentially optimal treatment option for Indian patients with hypertension and renal impairment.

Abbreviations

FDC: Fixed-Dose Combination, SBP: Systolic Blood Pressure, BP: Blood Pressure, DBP: Diastolic Blood Pressure, KDIGO: Kidney Disease: Improving Global Outcomes, ISH: International Society of Hypertension, RAS: Renin-Angiotensin System, ACEIs: Angiotensin-Converting Enzyme Inhibitors, ARBs: Angiotensin Receptor Blockers, CCB: Calcium Channel Blocker, eGFR: Estimated Glomerular Filtration Rate, UACR: Urine Albumin-Creatinine Ratio, CKD: Chronic Kidney Disease, ESRD: End-Stage Renal Disease

TEAM/0626/01