From the Guidelines
I strongly recommend initiating combination BP-lowering treatment with a RAS blocker, such as an ACE inhibitor or an ARB, and a dihydropyridine CCB or diuretic, as initial therapy for most patients with confirmed hypertension (BP ≥140/90 mmHg). This approach is supported by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The guidelines suggest that combination therapy is more effective in controlling blood pressure and reducing cardiovascular disease events compared to monotherapy.
When selecting a combination, it is essential to consider the patient's individual characteristics, such as age, comorbidities, and potential side effects. For example, in patients with symptomatic orthostatic hypotension, moderate-to-severe frailty, or elevated BP with a concomitant indication for treatment, alternative approaches may be necessary.
Key considerations for combination therapy include:
- Using a fixed-dose single-pill combination treatment to improve adherence 1
- Starting with a two-drug combination and increasing to a three-drug combination if blood pressure is not controlled, typically a RAS blocker with a dihydropyridine CCB and a thiazide/thiazide-like diuretic 1
- Avoiding the combination of two RAS blockers, such as an ACE inhibitor and an ARB, due to the increased risk of adverse effects 1
By following these guidelines and tailoring treatment to the individual patient, healthcare providers can effectively manage hypertension, reduce cardiovascular risk, and improve patient outcomes.
From the FDA Drug Label
The LIFE study was a multinational, double-blind study comparing losartan and atenolol in 9193 hypertensive patients with ECG-documented left ventricular hypertrophy. Patients with myocardial infarction or stroke within six months prior to randomization were excluded Patients were randomized to receive once daily losartan 50 mg or atenolol 50 mg. If goal blood pressure (<140/90 mmHg) was not reached, hydrochlorothiazide (12.5 mg) was added first and, if needed, the dose of losartan or atenolol was then increased to 100 mg once daily.
The initial dose of atenolol is 50 mg given as one tablet a day either alone or added to diuretic therapy. The full effect of this dose will usually be seen within one to two weeks. If an optimal response is not achieved, the dosage should be increased to atenolol 100 mg given as one tablet a day
The recommendation for additional medication or changes is to add hydrochlorothiazide (12.5 mg) if the goal blood pressure is not reached with losartan 50 mg or atenolol 50 mg. If needed, the dose of losartan or atenolol can be increased to 100 mg once daily. 2 3
- Key points:
- Add hydrochlorothiazide (12.5 mg) if goal blood pressure is not reached
- Increase losartan or atenolol dose to 100 mg once daily if needed
- Main considerations:
- Goal blood pressure: <140/90 mmHg
- Initial dose: losartan 50 mg or atenolol 50 mg once daily
From the Research
Recommendation for Additional Medication or Changes
- The study 4 suggests that patients with diabetes mellitus type 2 (DM2) and hypertension (HT) who are taking metformin and drugs blocking the renin angiotensin system (such as ACEI or ARB) should be aware of the risk of metformin-associated lactic acidosis, particularly in situations of dehydration or acute renal failure.
- The same study 4 recommends that patients should receive general advice on reducing dosage or withdrawing these drugs during acute intercurrent illness with dehydration, and that early diagnosis and treatment of metformin-associated lactic acidosis are crucial for patient outcome.
- Another study 5 emphasizes the importance of clinical reasoning in making decisions about medication, as evidence-based recommendations may not always apply to individual patients.
- There is no direct evidence in the provided studies to support specific recommendations for additional medication or changes, but the study 5 highlights the need for clinicians to use their judgment and consider individual patient factors when making decisions.
Considerations for Patient Care
- The study 6 discusses the health benefits of physical activity, but does not provide direct guidance on medication or changes.
- The study 7 introduces the Precautionary Principle, which suggests that in the absence of certainty, it is best to err on the side of caution, but does not provide specific recommendations for medication or changes.
- The study 8 discusses the importance of evidence-based research, but does not provide direct guidance on medication or changes.