What are commonly used drugs and their alternatives for treating hypertension, diabetes, and asthma?

Commonly Used Drugs and Their Alternatives

Hypertension

For patients with hypertension, first-line therapy should include ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers, with specific choices guided by comorbidities and patient characteristics. 1

First-Line Agents and Alternatives

ACE Inhibitors (Preferred in specific populations)

• Primary agents: Lisinopril, enalapril, benazepril, captopril 1
• When to use: First-line for patients with diabetes and albuminuria (UACR ≥30 mg/g), coronary artery disease, or heart failure 1
• Alternative if not tolerated: Switch to ARB (angiotensin receptor blocker) 1
• Key advantage: Once-daily dosing with lisinopril (20-80 mg/day), renoprotective effects 2, 3, 4

Angiotensin Receptor Blockers (ARBs)

• Primary agents: Losartan, valsartan, irbesartan, candesartan, olmesartan 1
• When to use: First-line for patients with diabetes and albuminuria when ACE inhibitors cause intolerable cough; preferred initial therapy in Black patients 1
• Alternative if not tolerated: Switch to ACE inhibitor 1
• Critical warning: Never combine ACE inhibitors with ARBs or direct renin inhibitors—increases adverse events (hyperkalemia, syncope, acute kidney injury) without added benefit 1

Thiazide-Like Diuretics (Preferred for most patients)

• Primary agents: Chlorthalidone (12.5-25 mg), indapamide 1
• Standard thiazides: Hydrochlorothiazide (25-50 mg) 1
• When to use: Appropriate for most hypertensive patients; long-acting thiazide-like agents (chlorthalidone, indapamide) preferred over hydrochlorothiazide for cardiovascular event reduction 1
• Alternative: Dihydropyridine calcium channel blockers if diuretics cause intolerable metabolic effects 1
• Monitoring: Check potassium levels—add potassium-sparing agent if K+ <3.5 mmol/L 1

Dihydropyridine Calcium Channel Blockers

• Primary agents: Amlodipine, nifedipine (long-acting), felodipine 1
• When to use: Appropriate first-line for most patients; preferred in Black patients (often combined with ARB or thiazide) 1
• Alternative: Thiazide-like diuretics 1

Population-Specific Recommendations

Black Patients

• Initial therapy: ARB + dihydropyridine CCB OR dihydropyridine CCB + thiazide-like diuretic 1
• Rationale: ACE inhibitors less effective as monotherapy in this population 1

Non-Black Patients

• Initial therapy: Low-dose ACE inhibitor or ARB + dihydropyridine CCB, then add thiazide-like diuretic 1

Patients with Diabetes

• Mandatory first-line: ACE inhibitor or ARB at maximum tolerated dose if UACR ≥300 mg/g (strong recommendation) or 30-299 mg/g (moderate recommendation) 1
• Without albuminuria: Any first-line agent acceptable (ACE inhibitors/ARBs show no superiority over thiazide-like diuretics or CCBs for cardioprotection) 1
• Target BP: <130/80 mmHg 1

Resistant Hypertension (Not Controlled on 3 Drugs Including Diuretic)

Fourth-line agent: Spironolactone (mineralocorticoid receptor antagonist) if serum potassium <4.5 mmol/L and eGFR >45 mL/min/1.73m² 1

Alternatives to spironolactone: Amiloride, doxazosin, eplerenone, clonidine, or beta-blockers 1

Drugs to AVOID or Minimize

Substances that impair BP control (discontinue or find alternatives): 1

• NSAIDs: Use acetaminophen, tramadol, or topical NSAIDs instead 1
• Decongestants (phenylephrine, pseudoephedrine): Use nasal saline, intranasal corticosteroids, or antihistamines 1
• Oral contraceptives: Use lowest dose (20-30 mcg ethinyl estradiol), progestin-only formulations, or non-hormonal methods 1
• Systemic corticosteroids: Switch to inhaled or topical formulations when possible 1
• Antidepressants (MAOIs, SNRIs, TCAs): Consider SSRIs as alternatives 1
• Amphetamines: Reduce dose or discontinue; consider behavioral therapies for ADHD 1

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Diabetes

For patients with diabetes and hypertension, ACE inhibitors or ARBs are mandatory first-line therapy, particularly when albuminuria is present. 1

Antihypertensive Therapy in Diabetic Patients

Blood Pressure Targets

• Goal: <130/80 mmHg 1
• Initiation threshold: Start pharmacotherapy at BP ≥140/90 mmHg (with lifestyle modifications) 1
• Aggressive initiation: Start two drugs or single-pill combination if BP ≥160/100 mmHg 1

Drug Selection Algorithm

1. With albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB at maximum tolerated dose 1
2. Add second agent: Thiazide-like diuretic (chlorthalidone or indapamide preferred) OR dihydropyridine CCB 1
3. Add third agent: Complete the triad (ACE inhibitor/ARB + thiazide-like diuretic + dihydropyridine CCB) 1
4. Resistant hypertension: Add spironolactone (if K+ <4.5 mmol/L and eGFR >45 mL/min/1.73m²) 1

Monitoring Requirements

• Renal function and potassium: Check within 3 months of starting ACE inhibitor, ARB, or diuretic, then every 6 months if stable 1, 5
• Annual minimum: At least yearly monitoring for all patients on these agents 1

Lipid Management in Diabetes

For diabetic patients >40 years without overt CVD but with ≥1 major CVD risk factor, statin therapy should be initiated to achieve LDL-C <100 mg/dL. 1

Statin Therapy

• Target: LDL-C reduction of 30-40% from baseline 1
• Primary agents: High-intensity statins (atorvastatin, rosuvastatin) for most patients 1
• Alternatives: Moderate-intensity statins if high-intensity not tolerated 1

Drug Interactions with Metformin

Metformin users must avoid excessive alcohol and be cautious with drugs affecting renal clearance. 6

Drugs Requiring Dose Adjustment or Monitoring

• OCT2/MATE inhibitors (ranolazine, vandetanib, dolutegravir, cimetidine): Increase metformin levels and lactic acidosis risk 6
• Carbonic anhydrase inhibitors (topiramate, zonisamide, acetazolamide): Increase lactic acidosis risk through metabolic acidosis 6
• Insulin secretagogues or insulin: Require lower doses when combined with metformin to prevent hypoglycemia 6

Drugs That Worsen Glycemic Control

Reduce metformin effectiveness: Thiazide diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blockers, isoniazid 6

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Asthma

Note: The provided evidence does not contain specific guidelines for asthma management. The question requested information on hypertension, diabetes, and asthma, but only hypertension and diabetes guidelines were supplied in the evidence base.

Considerations for Asthma Patients with Hypertension

Beta-blockers should generally be avoided in asthma patients, even cardioselective agents, due to potential bronchospasm risk. 1

Preferred antihypertensive alternatives for asthma patients:

• ACE inhibitors or ARBs (though ACE inhibitors may cause cough in 5-20% of patients) 1
• Calcium channel blockers 1
• Thiazide-like diuretics 1

Avoid systemic corticosteroids when possible for both conditions; use inhaled formulations for asthma and monitor BP closely if systemic steroids required 1