From the Guidelines
When managing blood pressure in patients with comorbidities, it is essential to consider the specific condition and choose medications that provide benefits beyond blood pressure control, such as ACE inhibitors or ARBs for patients with diabetes or heart failure, as recommended by the most recent guidelines 1.
Key Considerations
- For patients with diabetes, ACE inhibitors (like lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily) are preferred due to their renoprotective effects 1.
- In patients with heart failure, a combination of ACE inhibitors/ARBs, beta-blockers (metoprolol succinate 25-200 mg daily), and aldosterone antagonists (spironolactone 25-50 mg daily) is recommended to reduce mortality and hospitalizations 1.
- Patients with coronary artery disease benefit from beta-blockers and ACE inhibitors, while those with chronic kidney disease should receive ACE inhibitors or ARBs to slow disease progression 1.
- For asthmatics, calcium channel blockers (amlodipine 5-10 mg daily) or ACE inhibitors are safer than beta-blockers, which can trigger bronchospasm 1.
Special Considerations
- In elderly patients, start with lower doses and gradually titrate up, often beginning with a thiazide diuretic (hydrochlorothiazide 12.5-25 mg daily) or long-acting calcium channel blocker 1.
- For patients with resistant hypertension, consider adding a low dose of spironolactone as the 4th line agent, or alternative medications such as amiloride, doxazosin, eplerenone, clonidine, or beta-blockers 1.
Comorbidities and Medication Choices
- Atrial fibrillation: ARBs may reduce AF recurrence 1.
- Aortic disease: Beta blockers are recommended for patients with thoracic aorta disease 1.
- Chronic kidney disease: ACEI or ARB are preferred to slow disease progression 1.
- Diabetes: ACEI or ARB are recommended, especially if albuminuria is present 1.
- Heart failure: Diuretics, ACEI, ARB, beta blockers, and mineralocorticoid receptor antagonists are recommended for incremental BP control 1.
From the FDA Drug Label
Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). Losartan is indicated for the treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g) in patients with type 2 diabetes and a history of hypertension Lisinopril tablets USP are indicated to reduce signs and symptoms of systolic heart failure Amlodipine besylate tablets is indicated for the symptomatic treatment of chronic stable angina.
Special considerations for comorbid conditions include:
- Diabetes management: patients with diabetes may benefit from more aggressive treatment to a lower blood pressure goal 2
- Hyperlipidemia: patients with hyperlipidemia may benefit from more aggressive treatment to a lower blood pressure goal 2
- Heart failure: lisinopril is indicated to reduce signs and symptoms of systolic heart failure 3
- Angina: amlodipine is indicated for the symptomatic treatment of chronic stable angina 4
- Diabetic kidney disease: losartan is indicated for the treatment of diabetic nephropathy 2
- Black patients: some antihypertensive drugs have smaller blood pressure effects in black patients 2, 3, 4
From the Research
Blood Pressure Medications
- More than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents, either initially as combination therapy or as add-on therapy if monotherapy and lifestyle modifications do not achieve adequate blood pressure control 5
- Four main classes of medications are used in combination therapy for the treatment of hypertension: thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) 5
Special Considerations for Comorbid Conditions
- In black patients, at least one agent should be a thiazide diuretic or a calcium channel blocker 5
- Patients with heart failure with reduced ejection fraction should be treated initially with a beta blocker and an ACEI or ARB (or an angiotensin receptor-neprilysin inhibitor), followed by add-on therapy with a mineralocorticoid receptor antagonist and a diuretic based on volume status 5
- Treatment for patients with chronic kidney disease and proteinuria should include an ACEI or ARB plus a thiazide diuretic or a calcium channel blocker 5
- Patients with diabetes mellitus should be treated similarly to those without diabetes unless proteinuria is present, in which case combination therapy should include an ACEI or ARB 5
Combination Therapy
- Fixed-dosed combination regimens consisting of a calcium channel blocker and an angiotensin II type 1 receptor blocker represent a new addition to the available antihypertensive treatment options 6
- Clinical trials demonstrate that both the dihydropyridine calcium channel blocker amlodipine and angiotensin II receptor blockers are effective agents for the management of hypertension in individuals with or without cardiovascular disease 6
- The combination of amlodipine and an angiotensin II receptor blocker is well tolerated, including in patients with stage 2 hypertension and the elderly 6
Comparison of Antihypertensive Agents
- Valsartan, an angiotensin II antagonist, provides similar antihypertensive efficacy to lisinopril, an angiotensin-converting enzyme inhibitor, and appears to be associated with a reduced incidence of cough 7
- Diuretics and calcium-blocking drugs are more effective in elderly patients at lowering systolic blood pressure than ACE inhibitors and beta-blockers 8
- Monotherapy achieved control in only a small number of patients, and combination therapy will usually be required to achieve goal 8