What if blood pressure (BP) remains elevated after starting an Angiotensin Receptor Blocker (ARB)?

Management of Persistent Hypertension After Starting ARB Therapy

If blood pressure remains elevated after starting an ARB, you should follow a stepwise approach by first optimizing the ARB dose, then adding a calcium channel blocker, followed by a thiazide-like diuretic, and finally adding spironolactone as a fourth agent if needed. 1

First Steps When BP Remains Elevated After ARB Initiation

• Verify proper BP measurement technique using a validated device with appropriate cuff size, and confirm elevated readings with home or ambulatory BP monitoring 1
• Check medication adherence, as this is a common cause of inadequate BP control 1
• Evaluate for interfering substances (NSAIDs, certain medications) that may reduce ARB effectiveness 2
• Optimize lifestyle modifications including sodium restriction, weight loss, regular physical activity, and reduced alcohol intake 3

Stepwise Medication Adjustment Algorithm

Step 1: Optimize Current ARB Therapy

• Increase ARB to maximum tolerated dose before adding additional agents 1
• Consider once-daily dosing and single-pill combinations to improve adherence 1

Step 2: Add a Second Agent

• For non-Black patients: Add a dihydropyridine calcium channel blocker (DHP-CCB) 1
• For Black patients: If started on ARB monotherapy, add either a DHP-CCB or a thiazide/thiazide-like diuretic 1

Step 3: Add a Third Agent

• Add a thiazide/thiazide-like diuretic if not already included 1
• Ensure all three medications (ARB, CCB, diuretic) are at optimal doses 3

Step 4: Add a Fourth Agent

• Add spironolactone as the preferred fourth-line agent for resistant hypertension 3
• If spironolactone is not tolerated or contraindicated, alternatives include:
  • Amiloride
  • Doxazosin
  • Eplerenone
  • Clonidine
  • Beta-blocker 1

Special Considerations

• Monitor for hyperkalemia when using ARBs, especially when combined with spironolactone or in patients with renal impairment 2
• Avoid dual blockade of the renin-angiotensin system (combining ARB with ACE inhibitor or aliskiren) due to increased risks of hypotension, hyperkalemia, and renal dysfunction 2
• Target BP should be <130/80 mmHg for most patients, but individualize for elderly patients based on frailty 1
• Aim to achieve target BP within 3 months of treatment initiation 1

When to Refer to a Specialist

• If BP remains uncontrolled despite adherence to a four-drug regimen including a diuretic, refer to a provider with hypertension expertise 1, 4
• Consider evaluation for secondary causes of hypertension if BP remains difficult to control despite multiple medications 3

Common Pitfalls to Avoid

• Failing to confirm true resistant hypertension with out-of-office BP measurements before escalating therapy 3
• Not checking for medication adherence before adding additional agents 1
• Overlooking drug interactions that may reduce ARB effectiveness, particularly NSAIDs 2
• Inadequate dosing of medications before adding new agents 1
• Not allowing sufficient time (2-4 weeks) for full effect of dose adjustments before further changes 1