What are the considerations for switching antihypertensive medications in a patient with hypertension?

From the Guidelines

Switching antihypertensive medications in a patient with hypertension should be done under medical supervision, prioritizing optimization of the current treatment regimen, including health behavior change and diuretic-based treatment, before considering alternative medications. When switching, it's typically best to gradually taper the first medication while slowly introducing the new one to avoid rebound hypertension, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1. The decision to switch medications should be based on specific reasons such as inadequate blood pressure control, intolerable side effects, or development of contraindications.

Some key considerations for switching antihypertensive medications include:

• Optimizing the current treatment regimen, including maximally tolerated doses of diuretics and optimal choice of diuretic, before adding new medications 1
• Adding a low dose of spironolactone as the 4th line agent in patients whose serum potassium is <4.5 mmol/L and whose eGFR is >45 ml/min/1.73m2 to achieve BP targets, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1
• Considering alternative medications, such as ACE inhibitors, ARB, CCB, or diuretics, if no compelling clinical indication for selection of a BP-lowering medication, as recommended by the European Society of Cardiology/European Society of Hypertension guidelines 1
• Avoiding simultaneous use of ACE inhibitors and ARB, as recommended by the European Society of Cardiology/European Society of Hypertension guidelines 1

During medication transitions, more frequent blood pressure monitoring is essential, ideally with home measurements twice daily for at least two weeks, to evaluate the effectiveness of the new regimen. The full effect of most antihypertensive medications takes 2-4 weeks to develop, so patience is needed when evaluating the effectiveness of the new regimen. Medication switches work because different drug classes target different blood pressure control mechanisms in the body, allowing for personalized treatment based on individual response and tolerance.

It's also important to consider the patient's individual characteristics, such as the presence of subclinical organ damage, clinical cardiovascular disease, renal disease, or diabetes, when selecting antihypertensive medications, as recommended by the 2007 guidelines for the management of arterial hypertension 1. Ultimately, the goal of switching antihypertensive medications is to achieve optimal blood pressure control, reduce morbidity and mortality, and improve quality of life for patients with hypertension.

From the FDA Drug Label

Many patients will require more than 1 drug to achieve blood pressure goals. 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). These considerations may guide selection of therapy. Losartan may be administered with other antihypertensive agents. Amlodipine besylate tablets may be used alone or in combination with other antihypertensive agents.

When switching antihypertensive medications in a patient with hypertension, key considerations include:

• The need for more than one drug to achieve blood pressure goals
• Potential differences in blood pressure effects in certain populations, such as Black patients
• Additional approved indications and effects of the antihypertensive drugs
• The possibility of using the new medication in combination with other antihypertensive agents It is essential to consider these factors and select therapy based on individual patient needs and characteristics 2, 3.

From the Research

Considerations for Switching Antihypertensive Medications

• The decision to switch antihypertensive medications is often based on insufficient blood pressure control, with a study finding that 73.7% of switches were due to this reason 4.
• Other considerations for switching medications include aiming for a better 24-hour effect and increased cardiovascular risk of the patients 4.
• When switching medications, it is essential to consider the patient's demographic information, cardiovascular risk factors, and blood pressure values 4.
• The choice of antihypertensive medication should be based on the patient's specific needs, with certain medications being more suitable for certain patient populations, such as black patients or those with heart failure or chronic kidney disease 5.

Classes of Antihypertensive Medications

• There are four main classes of medications 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.
• ACEIs and ARBs should not be used simultaneously, and patients with heart failure should be treated initially with a beta blocker and an ACEI or ARB 5.
• Calcium channel blockers and thiazide diuretics are suitable alternatives for patients who cannot tolerate ACEIs or ARBs 5, 6.

Efficacy and Safety of Antihypertensive Medications

• A prospective study found that beta-blockers, calcium channel blockers, and angiotensin receptor blockers have similar efficacy in reducing blood pressure, with no significant adverse reactions observed 7.
• Another study found that ARBs have a comparable effect to ACEIs in lowering blood pressure levels, but with better pharmacological tolerability 6.
• The choice of antihypertensive medication should be based on the patient's individual needs and medical history, with consideration given to the potential benefits and risks of each medication 5, 6, 7.