Alternative Antihypertensive Medication Options Besides ARBs and CCBs
Besides Angiotensin Receptor Blockers (ARBs) and Calcium Channel Blockers (CCBs), the main alternative antihypertensive medication options include thiazide/thiazide-like diuretics, ACE inhibitors, beta-blockers, aldosterone antagonists, alpha-blockers, and centrally acting agents. 1
First-Line Alternatives
Thiazide and Thiazide-like Diuretics: Recommended as first-line therapy in many guidelines, particularly effective in black patients and elderly patients 1
ACE Inhibitors (ACEIs): Similar mechanism to ARBs but with different side effect profile (notably cough); particularly beneficial in patients with diabetes, heart failure, or kidney disease 1
Beta-Blockers: Effective antihypertensives, especially beneficial in patients with coronary artery disease or heart failure 1, 2
Second-Line and Add-On Options
Aldosterone Antagonists (e.g., spironolactone, eplerenone): Particularly effective in resistant hypertension as fourth-line agents 1
Alpha-Blockers (e.g., doxazosin): Useful as add-on therapy in resistant hypertension 1
Centrally Acting Agents (e.g., clonidine): Can be considered when other options are contraindicated or ineffective 1
Medication Selection Based on Patient Demographics
For Black Patients: Thiazide diuretics and CCBs are more effective than ACEIs, ARBs, or beta-blockers 1, 3
For Non-Black Patients: ACEIs, ARBs, CCBs, and thiazide diuretics are all reasonable first-line options 1
For Elderly Patients: CCBs and thiazide diuretics may be preferred due to better efficacy 1
Combination Therapy Considerations
Triple therapy is often required in resistant hypertension, typically including a renin-angiotensin system blocker (ACEI or ARB), CCB, and thiazide diuretic 4
When adding a fourth medication, spironolactone is recommended if serum potassium is <4.5 mmol/L and eGFR is >45 ml/min/1.73m² 1
If spironolactone is contraindicated or not tolerated, alternatives include amiloride, doxazosin, eplerenone, clonidine, or beta-blockers 1
Special Populations
Diabetes: ACEIs or ARBs are preferred first-line agents, particularly with albuminuria 1
Chronic Kidney Disease: ACEIs or ARBs are recommended, with loop diuretics preferred over thiazides when eGFR <30 ml/min/1.73m² 1
Heart Failure: Beta-blockers, ACEIs/ARBs, and aldosterone antagonists have mortality benefits 1
Coronary Artery Disease: Beta-blockers and RAS blockers (ACEIs/ARBs) are recommended 1, 5
Common Pitfalls and Caveats
Combining ACEIs with ARBs is not recommended due to increased risk of adverse events without additional benefit 1
Monitor serum creatinine, eGFR, and potassium levels at least annually in patients on ACEIs, ARBs, or diuretics 1
When using aldosterone antagonists with ACEIs or ARBs, there is increased risk of hyperkalemia, requiring close monitoring 1
Beta-blockers may be less effective as monotherapy in elderly and black patients 2
The selection of antihypertensive medication should be guided by comorbidities, demographic factors, and prior medication tolerance, with the ultimate goal of reducing morbidity and mortality through effective blood pressure control 1.