What is the recommended approach for prescribing anti-hypertension (high blood pressure) drugs?

Recommended Approach for Prescribing Anti-Hypertension Drugs

For most patients with hypertension, initial therapy should include a thiazide-type diuretic (preferably chlorthalidone) as first-line treatment, either alone or in combination with other antihypertensive agents depending on blood pressure severity. 1, 2

Initial Drug Selection Algorithm

Step 1: Assess Hypertension Severity

• Stage 1 Hypertension (130-139/80-89 mmHg):

  • Start with a single antihypertensive drug (monotherapy)
  • Target BP goal: <130/80 mmHg 1

• Stage 2 Hypertension (≥140/90 mmHg):

  • If BP is >20/10 mmHg above target: Start with 2 first-line agents of different classes
  • Consider fixed-dose combinations to improve adherence 1, 2

Step 2: Select First-Line Agents Based on Patient Characteristics

General Population:

• First choice: Thiazide-type diuretic (preferably chlorthalidone 12.5-25 mg daily) 1, 2, 3

  • Chlorthalidone is more effective than hydrochlorothiazide in lowering systolic BP as demonstrated by 24-hour ambulatory BP monitoring 3
  • Low-dose thiazides (chlorthalidone 12.5-25 mg or hydrochlorothiazide 12.5-25 mg) provide effective BP reduction with fewer metabolic side effects 4

• Alternative first-line options:

  • ACE inhibitors
  • ARBs
  • Calcium channel blockers (CCBs) 1, 2

Special Populations:

• Black patients: Thiazide diuretic or CCB as initial therapy 1, 2

  • Amlodipine 5-10 mg daily is an effective option 5

• Patients with diabetes and albuminuria: ACE inhibitor or ARB 2

• Patients with chronic kidney disease:

  • eGFR >30 mL/min: ACE inhibitor or ARB
  • eGFR <30 mL/min: Consider loop diuretic instead of thiazide 2

Combination Therapy Approach

Preferred Combinations:

• Thiazide diuretic + ACE inhibitor
• Thiazide diuretic + ARB
• CCB + ACE inhibitor
• CCB + ARB
• CCB + thiazide diuretic 1, 2

Combinations to Avoid:

• ACE inhibitor + ARB (increased risk of adverse effects without additional benefit) 1, 2

Monitoring and Titration

1. Initial follow-up: 2-4 weeks after starting therapy

2. Monitoring parameters:

   • Blood pressure (office and home measurements)
   • Serum electrolytes, creatinine/eGFR (especially with ACE inhibitors, ARBs, or diuretics)
   • Assess for side effects 2

3. Titration strategy:

   • If BP not at goal, increase dose of initial agent or add a second agent
   • Most patients will require ≥2 medications to achieve target BP 1

Management of Resistant Hypertension

If BP remains above target despite optimal doses of 3 different classes of antihypertensive medications (including a diuretic):

1. Add a mineralocorticoid receptor antagonist (spironolactone)
2. Consider adding alpha-blockers or centrally acting agents
3. Consider referral to a hypertension specialist 2

Important Considerations

• Target BP goals:

  • General population: <130/80 mmHg
  • Older adults (≥65 years): SBP <130 mmHg if tolerated
  • Very elderly (>80 years): 140-145 mmHg if well tolerated 1, 2

• Diuretic benefits:

  • Enhanced antihypertensive efficacy in multidrug regimens
  • Proven cardiovascular event reduction in clinical trials
  • More affordable than other agents 2, 6
  • Reduced risk of stroke and cardiovascular events 1, 7

• Common pitfalls to avoid:

  • Underutilization of diuretics despite strong evidence supporting their use 6
  • Using hydrochlorothiazide instead of chlorthalidone (chlorthalidone has superior 24-hour BP control) 3
  • Initiating two-drug therapy in elderly patients without careful BP monitoring (risk of hypotension) 1
  • Neglecting to monitor electrolytes, especially potassium, when using diuretics 2

By following this evidence-based approach to antihypertensive therapy, clinicians can effectively reduce blood pressure and minimize cardiovascular risk in patients with hypertension.