What is the drug of choice for managing blood pressure fluctuations, specifically hypertension?

Management of Blood Pressure Fluctuations: First-Line Pharmacological Approach

For managing hypertension, a combination of ACE inhibitors/ARBs with either dihydropyridine calcium channel blockers or thiazide/thiazide-like diuretics is recommended as first-line therapy for most patients with confirmed hypertension. 1

First-Line Pharmacological Options

• Among all blood pressure-lowering drugs, ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics (thiazides and thiazide-like drugs such as chlorthalidone and indapamide) have demonstrated the most effective reduction of BP and cardiovascular events 1
• For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination BP-lowering treatment is recommended as initial therapy 1
• Preferred combinations are a RAS blocker (either an ACE inhibitor or an ARB) with a dihydropyridine CCB or diuretic 1, 2
• Fixed-dose single-pill combinations are recommended to improve adherence 1

Treatment Algorithm Based on Patient Demographics

• For non-Black patients, start with low-dose ACE inhibitor or ARB 2
• For Black patients, start with low-dose ARB plus either dihydropyridine CCB or dihydropyridine CCB plus thiazide/thiazide-like diuretic 2
• Monotherapy should be considered in specific populations: patients aged ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or elevated BP (systolic BP 120–139 mmHg) 1

Escalation of Therapy for Uncontrolled BP

• If BP is not controlled with a two-drug combination, increasing to a three-drug combination is recommended, usually a RAS blocker with a dihydropyridine CCB and a thiazide/thiazide-like diuretic 1
• If BP is not controlled with a three-drug combination, adding spironolactone should be considered 1
• If spironolactone is not effective or tolerated, consider eplerenone, beta-blockers, centrally acting medications, alpha-blockers, hydralazine, or potassium-sparing diuretics 1

Important Considerations and Caveats

• Combining two RAS blockers (ACE inhibitor and an ARB) is not recommended due to increased risk of hyperkalemia and renal dysfunction without additional BP benefit 1, 2
• Beta-blockers should be combined with other major BP-lowering drug classes when there are compelling indications for their use (e.g., angina, post-MI, heart failure with reduced ejection fraction) 1
• Thiazide or thiazide-like diuretics may cause metabolic abnormalities, especially when combined with beta-blockers, and should be used with caution in patients with metabolic syndrome or at high risk of diabetes 1, 3
• Chlorthalidone may be preferred over hydrochlorothiazide for resistant hypertension due to greater 24-hour BP reduction 2, 4

Timing and Monitoring

• Medications should be taken at the most convenient time of day to improve adherence 1
• Patients should be encouraged to take medications at the same time each day and in a consistent setting 1
• BP should ideally be treated to target within 3 months to retain patient confidence, ensure long-term adherence, and reduce cardiovascular risk 1, 2
• Target BP reduction should be at least 20/10 mmHg, ideally to <130/80 mmHg for most adults 2, 5
• Monitor serum electrolytes and renal function within 1 month of adding or increasing the dose of diuretics or ACE inhibitors 2

Special Populations

• For elderly patients (>80 years) or frail individuals, consider monotherapy initially and individualize BP targets based on frailty 2
• For patients with left ventricular hypertrophy, losartan is indicated to reduce the risk of stroke, though this benefit may not apply to Black patients 6
• For patients with diabetic nephropathy, losartan is indicated for treatment of diabetic nephropathy with elevated serum creatinine and proteinuria 6

By following this evidence-based approach to managing hypertension, clinicians can effectively control blood pressure fluctuations and reduce the risk of cardiovascular events in their patients.