From the Guidelines
The initial approach to managing refractory hypertension involves excluding causes of pseudoresistance, optimizing the current treatment regimen, and considering screening for secondary causes as appropriate. When managing refractory hypertension, it is essential to first exclude causes of pseudoresistance, such as poor BP measurement technique, white coat effect, nonadherence, and suboptimal choices in antihypertensive therapy, as well as substance-induced increases in BP 1.
Key Considerations
- Optimize the current treatment regimen, including health behavior change and diuretic-based treatment, with maximally tolerated doses of diuretics and optimal choice of diuretic 1.
- Add 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.
- If spironolactone is contraindicated or not tolerated, alternatives include amiloride, doxazosin, eplerenone, clonidine, and beta-blockers, or any available antihypertensive class not already in use 1.
- Resistant hypertension should be managed in specialist centers with sufficient expertise and resources necessary to diagnose and treat this condition 1.
Lifestyle Modifications
- Sodium restriction (<2.3g/day)
- Regular physical activity
- Weight management
- Limited alcohol consumption
- A DASH diet
Secondary Causes
- Obstructive sleep apnea
- Primary aldosteronism
- Renal artery stenosis
- Chronic kidney disease
Blood Pressure Measurement
- Verify blood pressure measurement technique
- Home or ambulatory monitoring may be needed to rule out white-coat hypertension 1.
By following this approach, healthcare providers can ensure optimal management of refractory hypertension, minimizing morbidity, mortality, and improving quality of life for patients with this condition.
From the FDA Drug Label
1.2 Hypertension Spironolactone tablets are indicated as add-on therapy for the treatment of hypertension, to lower blood pressure in patients who are not adequately controlled on other agents. Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)
The initial approach to managing refractory hypertension involves using spironolactone as add-on therapy to lower blood pressure in patients not adequately controlled on other agents.
- The treatment should be guided by published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee 2.
- It is also important to note that many patients will require more than one drug to achieve blood pressure goals.
- The dosage and administration of spironolactone for the treatment of essential hypertension is outlined in the drug label, with a recommended initial daily dose of 25 mg to 100 mg 2.
From the Research
Initial Approach to Refractory Hypertension
The initial approach to managing refractory hypertension involves a thorough evaluation to confirm the diagnosis and optimize treatment. This includes:
- Checking drug adherence and evaluating the antihypertensive scheme, emphasizing the use of diuretics and adequate combination and dosages of other drugs 3
- Ambulatory blood pressure monitoring (ABPM) at baseline to classify patients into true refractory hypertension (uncontrolled ambulatory BPs) and white-coat refractory hypertension (controlled ambulatory BPs) 3
- Lifestyle changes and use of adequate combinations of antihypertensive agents from different classes 3, 4
Diagnostic Considerations
Diagnostic considerations for refractory hypertension include:
- Excluding medication nonadherence and the white coat effect 4
- Evaluating for secondary causes of hypertension, such as obstructive sleep apnea, primary aldosteronism, renovascular disease, and chronic kidney disease 5, 6
- Assessing for factitious or induced hypertension, particularly in patients with a history of psychiatric illness or employment in the medical field 7
Treatment Options
Treatment options for refractory hypertension include:
- Combination therapy with a diuretic, a long-acting calcium channel blocker, an angiotensin-converting enzyme inhibitor, a beta blocker, and a mineralocorticoid receptor antagonist 5
- Addition of spironolactone or amiloride to the standard 3-drug antihypertensive regimen 4
- Novel interventional therapies, such as baroreflex activation and renal denervation, for patients who have failed other treatments 5