What are the common medications used in general practice?

Common Medications Used in General Practice

The most commonly prescribed medications in general practice include ACE inhibitors (lisinopril), calcium channel blockers (amlodipine), and beta-blockers (metoprolol) for hypertension management, which represent the cornerstone of cardiovascular disease prevention. 1

Antihypertensive Medications

Hypertension is one of the most common conditions treated in general practice, and these medications are frequently prescribed:

First-line Agents

• ACE Inhibitors:

  • Lisinopril (most prescribed in US)
  • Ramipril (most prescribed in UK/EU)
  • Enalapril
  • Benazepril
  • Starting doses range from 2.5-10mg daily with target doses of 20-40mg daily 1

• Angiotensin Receptor Blockers (ARBs):

  • Losartan
  • Candesartan
  • Valsartan
  • Particularly useful when ACE inhibitors cause cough 1

• Calcium Channel Blockers:

  • Amlodipine (most common)
  • Diltiazem
  • Nifedipine
  • Typically started at 2.5-5mg daily for amlodipine 1

• Thiazide/Thiazide-like Diuretics:

  • Hydrochlorothiazide
  • Chlorthalidone
  • Indapamide
  • Usually dosed at 12.5-25mg daily 1

• Beta-Blockers:

  • Metoprolol
  • Bisoprolol
  • Carvedilol
  • Atenolol 1

Second-line/Add-on Agents

• Aldosterone Antagonists:

  • Spironolactone
  • Eplerenone 1

• Alpha Blockers:

  • Doxazosin
  • Terazosin 1

Medication Selection Algorithm for Hypertension

1. Non-Black Patients:

   • Start with low-dose ACE inhibitor/ARB
   • Add dihydropyridine calcium channel blocker
   • Add thiazide/thiazide-like diuretic
   • Add spironolactone or other agents (doxazosin, eplerenone, clonidine, beta-blocker) 1

2. Black Patients:

   • Start with low-dose ARB + calcium channel blocker OR calcium channel blocker + thiazide diuretic
   • Increase to full dose
   • Add diuretic or ACE inhibitor/ARB
   • Add spironolactone or other agents 1

Medications for Chronic Kidney Disease

For patients with diabetes and chronic kidney disease:

• First choice: ACE inhibitor or ARB
• Additional agents: Diuretic, beta-blocker, or calcium channel blocker to reach target BP <130/80 mmHg 1

Medications for Heart Failure

For heart failure with reduced ejection fraction:

• ACE inhibitors (e.g., lisinopril, enalapril)
• Beta-blockers (e.g., carvedilol, metoprolol succinate, bisoprolol)
• Aldosterone antagonists (e.g., spironolactone, eplerenone)
• ARBs when ACE inhibitors are not tolerated 1

Common Pitfalls and Caveats

1. Medication Interactions: Be cautious with:

   • NSAIDs: Can reduce effectiveness of ACE inhibitors, ARBs, and diuretics
   • Potassium supplements: Risk of hyperkalemia with ACE inhibitors, ARBs, and aldosterone antagonists
   • Certain antidepressants (MAOIs, SNRIs, TCAs): May increase blood pressure 1

2. Monitoring Requirements:

   • ACE inhibitors/ARBs: Check renal function and potassium within 1-2 weeks of initiation
   • Diuretics: Monitor electrolytes, particularly potassium
   • Target blood pressure should be <130/80 mmHg for most patients 1

3. Medications That May Cause Elevated Blood Pressure:

   • Oral contraceptives
   • NSAIDs
   • Corticosteroids
   • Decongestants (pseudoephedrine)
   • Certain antidepressants
   • Stimulants 1

Elderly Considerations

For elderly patients (≥75 years):

• Target BP of <140/90 mmHg is generally appropriate
• Avoid excessive BP lowering (diastolic <70 mmHg)
• Consider simplified regimens to improve adherence
• Monitor for orthostatic hypotension 2

By understanding these common medications and their appropriate use, general practitioners can effectively manage the most prevalent conditions seen in primary care practice.