Can blood pressure medications be increased without a blood pressure log based on an elevated office reading of hypertension?

From the Guidelines

It is not recommended to increase blood pressure medications without a blood pressure log, as this approach may lead to overtreatment due to potential "white coat hypertension" effects, and instead, healthcare providers should ideally review multiple readings taken at home over several days or weeks before making any adjustments to medications like lisinopril, amlodipine, or hydrochlorothiazide. According to the 2020 international society of hypertension global hypertension practice guidelines 1, if seated office BP is >140/90 mm Hg in patients managed with three or more antihypertensive medications at optimal doses, the first step is to exclude causes of pseudoresistance, including poor BP measurement technique, white coat effect, nonadherence, and suboptimal choices in antihypertensive therapy.

The guidelines suggest optimizing the current treatment regimen, including health behavior change and diuretic-based treatment, before considering adding new medications 1. Additionally, the 2017 acc/aha/aapa/abc/acpm/ags/apha/ash/aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults recommends confirming the diagnosis of hypertension with out-of-office blood pressure measurements, such as home blood pressure monitoring (HBPM) or ambulatory blood pressure monitoring (ABPM), especially in cases where white coat effect is suspected 1.

Some key points to consider when managing hypertension include:

• Reviewing multiple blood pressure readings taken at home over several days or weeks to confirm the diagnosis of hypertension
• Excluding causes of pseudoresistance, such as poor BP measurement technique, white coat effect, nonadherence, and suboptimal choices in antihypertensive therapy
• Optimizing the current treatment regimen, including health behavior change and diuretic-based treatment, before considering adding new medications
• Considering the use of HBPM or ABPM to confirm the diagnosis of hypertension, especially in cases where white coat effect is suspected
• Being cautious when increasing blood pressure medications, as this may lead to overtreatment and increase the risk of side effects, such as dizziness, fatigue, or electrolyte imbalances.

From the Research

Increasing Blood Pressure Medication

• Increasing blood pressure medication without a blood pressure log based on an elevated office reading is a complex decision that requires careful consideration of various factors, including the patient's medical history, current medication regimen, and lifestyle habits 2, 3.
• The American Family Physician study suggests that combination therapy is often necessary to achieve adequate blood pressure control, and that four main classes of medications are used in combination therapy: thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) 2.
• However, the study also notes that ACEIs and ARBs should not be used simultaneously, and that patients with specific conditions, such as heart failure or chronic kidney disease, require tailored treatment approaches 2.

Office Blood Pressure Readings

• The study published in Blood Pressure Monitoring found that discarding the first office blood pressure reading does not improve the association of office blood pressure with ambulatory blood pressure monitoring (ABPM) readings 4.
• The study suggests that using all three office blood pressure readings, rather than discarding the first one, may provide a more accurate assessment of blood pressure control 4.
• Another study published in Medical Archives found that different combinations of antihypertensive therapy can be effective in reducing blood pressure and improving arterial stiffness, but that the choice of medication should be individualized based on patient characteristics and medical history 5.

Medication Efficacy and Tolerability

• The study published in the Journal of Human Hypertension found that lisinopril and metoprolol are both effective in reducing blood pressure, but that lisinopril may be better tolerated and have a more favorable effect on quality of life 6.
• The study suggests that the choice of medication should take into account not only efficacy, but also tolerability and potential impact on quality of life 6.