When do you increase a patient's antihypertensive medication?

When to Increase Antihypertensive Medication

Antihypertensive medication should be increased when blood pressure remains above target despite current therapy, with the goal of achieving BP <130/80 mmHg within 3 months of treatment initiation. 1

Key Indications for Medication Intensification

• Increase medication when office BP readings remain ≥140/90 mmHg or home BP readings remain ≥135/85 mmHg despite current therapy 1
• Medication should be intensified if BP target is not achieved within 3 months of treatment initiation 1
• For patients with Grade 2 hypertension (≥160/100 mmHg), immediate medication intensification is warranted if BP remains uncontrolled 1
• Treatment intensification is necessary regardless of medication adherence status, as studies show that intensification significantly improves BP control even when adherence is suboptimal 2

Stepwise Approach to Medication Intensification

For Non-Black Patients:

1. Start with low dose ACEI/ARB and increase to full dose if BP remains uncontrolled 1
2. Add a dihydropyridine calcium channel blocker (DHP-CCB) if BP remains above target 1
3. Add a thiazide/thiazide-like diuretic if BP remains uncontrolled 1
4. Add spironolactone as fourth-line therapy for resistant hypertension 1, 3
5. Consider alternatives such as amiloride, doxazosin, eplerenone, clonidine or beta-blocker if spironolactone is not tolerated 1, 3

For Black Patients:

1. Start with low dose ARB + DHP-CCB or DHP-CCB + thiazide/thiazide-like diuretic 1
2. Increase to full dose if BP remains uncontrolled 1
3. Add diuretic or ACE/ARB (whichever was not included in initial therapy) 1
4. Add spironolactone or alternatives as fourth-line therapy 1, 3

Special Considerations

• For elderly patients (>80 years) or frail individuals, treatment intensification should be more gradual with individualized BP targets based on frailty 1
• For patients with resistant hypertension (BP uncontrolled despite three medications including a diuretic), adding spironolactone has shown the greatest efficacy 3
• Medication intensification should occur at each visit where BP is elevated, as clinical inertia (failure to intensify therapy) is a major contributor to poor BP control 4
• Consider medication adherence before intensification, but do not withhold intensification solely due to suspected non-adherence, as research shows that intensification improves outcomes regardless of adherence status 2

Common Pitfalls to Avoid

• Waiting too long to intensify therapy - failure to intensify medications at visits with elevated BP contributes significantly to poor BP control 4
• Assuming poor adherence is the only reason for uncontrolled BP - studies show that even patients with good adherence often require medication intensification 5, 6
• Reducing medication intensity without clear indication - evidence shows that one year after resistant hypertension determination, fewer patients were taking recommended medications, potentially worsening outcomes 2
• Failing to assess for and address secondary causes of hypertension before continuing to intensify medications 3

Remember that the ultimate goal is to reduce BP by at least 20/10 mmHg, ideally to <130/80 mmHg, to minimize cardiovascular risk and improve mortality and quality of life outcomes 1.