From the Guidelines
The most effective combination for treating resistant hypertension typically includes a thiazide diuretic, an ACE inhibitor or angiotensin receptor blocker, and a calcium channel blocker, with the addition of spironolactone 25-50mg daily as a fourth-line agent, as recommended by the 2024 ESC guidelines 1. When selecting a combination of medications, it is essential to consider the patient's individual needs and potential side effects. The 2024 ESC guidelines suggest that the combination of a thiazide diuretic, an ACE inhibitor or angiotensin receptor blocker, and a calcium channel blocker provides a good foundation for treating resistant hypertension 1. Some key points to consider when treating resistant hypertension include:
- Reinforcing lifestyle measures, such as sodium restriction, and optimizing the current treatment regimen, including health behavior change and diuretic-based treatment 1
- Adding a low dose of spironolactone as the 4th line agent in those whose serum potassium is <4.5 mmol/L and whose eGFR is >45 ml/min/1.73m2 to achieve BP targets 1
- Considering alternatives to spironolactone, such as eplerenone, amiloride, doxazosin, clonidine, and beta-blockers, if spironolactone is contraindicated or not tolerated 1
- Managing resistant hypertension in specialist centers with sufficient expertise and resources necessary to diagnose and treat this condition 1 It is crucial to prioritize the patient's safety and well-being when selecting a combination of medications, and to carefully monitor their response to treatment and adjust the regimen as needed. The 2024 ESC guidelines provide a comprehensive framework for treating resistant hypertension, and should be consulted for further guidance 1.
From the Research
Treatment of Resistant Hypertension
The treatment of resistant hypertension typically involves a combination of lifestyle modifications and medications.
- Lifestyle modifications include reduced sodium and alcohol intake, regular physical activity, weight loss, and discontinuation of substances that can interfere with blood pressure control 2.
- The initial medication management usually includes adding or increasing the dose of a diuretic, which is effective in lowering the blood pressure of a large number of patients with resistant hypertension 3.
Medication Combinations
The best combination of medications for treating resistant hypertension typically includes:
- An angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) 4, 2, 5, 6
- A calcium channel blocker 4, 2, 5, 6
- A diuretic 4, 2, 3, 5, 6
- If a fourth drug is needed, evidence supports the addition of a mineralocorticoid receptor antagonist, such as spironolactone 2, 6
Additional Management Options
Additional management options for resistant hypertension include: