When switching between two antihypertensive medications (hypertension medications) for a patient with hypertension, is titration (adjusting the dose) necessary?

From the Guidelines

When switching between two antihypertensive medications for a patient with hypertension, a careful titration approach is necessary to prevent rebound hypertension and maintain blood pressure control. This approach is supported by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults, which recommends a stepped-care approach defined by the initiation of antihypertensive drug therapy with a single agent followed by the sequential titration of the dose and addition of other agents 1. The titration process involves maintaining one medication at its current dose while gradually tapering the first medication to be discontinued, and simultaneously introducing the new medication at a low dose. For example, if switching from amlodipine to lisinopril while maintaining hydrochlorothiazide, reduce amlodipine by 50% while starting lisinopril at a low dose (e.g., 5-10 mg daily), then completely discontinue amlodipine after 1-2 weeks while adjusting the lisinopril dose as needed. Some key points to consider when titrating antihypertensive medications include:

• Blood pressure should be monitored frequently during the transition, ideally 2-3 times weekly
• Special consideration is needed for certain medication classes, such as beta-blockers, which require particularly slow tapering to avoid rebound effects, and clonidine, which should never be stopped abruptly
• The titration process typically takes 2-4 weeks depending on the specific medications involved and the patient's response
• The use of fixed-dose combination products can also be beneficial in improving adherence and increasing the rate of blood pressure control, as recommended by the 2013 ESH/ESC guidelines for the management of arterial hypertension 1. However, the most recent and highest quality study, the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline, takes precedence in guiding clinical practice 1.

From the FDA Drug Label

Adjust dosage according to blood pressure goals. In general, wait 7 to 14 days between titration steps. When switching between two antihypertensive medications, titration is necessary to adjust the dose according to the patient's blood pressure goals. The dosage should be adjusted and the patient should be monitored, waiting 7 to 14 days between titration steps unless rapid titration is clinically warranted and the patient is assessed frequently 2.

• Key considerations for titration include the patient's blood pressure goals and individual response to the medication.
• Titration steps should be guided by regular monitoring of the patient's blood pressure.

From the Research

Titration in Antihypertensive Medication Switching

• The provided studies do not directly address the necessity of titration when switching between two antihypertensive medications for a patient with hypertension.
• However, the studies suggest that combination therapy is often necessary to achieve adequate blood pressure control, and that fixed-dose combinations can be effective and well-tolerated 3, 4, 5, 6.
• The decision to switch antihypertensive medications is often based on insufficient blood pressure control, aiming for a better 24-hour effect, or increased cardiovascular risk of the patients 7.
• When switching medications, it is important to consider the patient's individual characteristics, such as the presence of diabetes or chronic kidney disease, and to select medications that are complementary and have an improved adverse effect profile when combined 5, 6.
• The use of fixed-dose combinations can improve patient acceptance and persistence in taking medications as prescribed, which can lead to better blood pressure control 6.