From the Guidelines
Severe hypertension requires immediate medical attention, and treatment should begin with intravenous medications in a hospital setting for hypertensive emergencies with organ damage, or oral medications for hypertensive urgencies without organ damage, with a goal to lower blood pressure gradually, aiming for a 25% reduction in the first hour and normalization over 24-48 hours 1.
Treatment Options
The treatment of severe hypertension involves a combination of lifestyle modifications and pharmacological therapy. According to the most recent guidelines, patients with confirmed office-based blood pressure ≥140/90 mmHg should have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals 1.
- For hypertensive urgencies, a common approach is to use labetalol 200-400 mg orally, followed by 200-300 mg every 6-8 hours, or clonidine 0.1-0.2 mg initially, followed by 0.1 mg hourly until blood pressure is controlled.
- For hypertensive emergencies, IV medications like nicardipine (initial dose 5 mg/hr, titrated by 2.5 mg/hr every 5-15 minutes, maximum 15 mg/hr), labetalol (20-80 mg bolus every 10 minutes or 0.5-2 mg/min infusion), or clevidipine (1-2 mg/hr initial, doubled every 90 seconds until near goal) are preferred.
Long-term Management
After stabilization, patients need comprehensive evaluation for underlying causes and long-term management with combination oral antihypertensives (typically including a calcium channel blocker, ACE inhibitor/ARB, and thiazide diuretic), lifestyle modifications, and regular follow-up to prevent recurrence and target organ damage 1.
- Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes (ACE inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers) 1.
- Multiple-drug therapy is generally required to achieve blood pressure targets, and combinations of ACE inhibitors and angiotensin receptor blockers should not be used 1.
Key Considerations
- Blood pressure should be lowered gradually to prevent organ hypoperfusion, aiming for a 25% reduction in the first hour and normalization over 24-48 hours 1.
- Patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine should be treated with an ACE inhibitor or angiotensin receptor blocker at the maximum tolerated dose indicated for blood pressure treatment 1.
From the FDA Drug Label
Doxazosin tablets, USP are indicated for the treatment of hypertension, to lower blood pressure. Many patients will require more than one drug to achieve blood pressure goals Doxazosin tablets, USP may be used alone or in combination with other antihypertensives. Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure. Many patients will require more than 1 drug to achieve blood pressure goals. Lisinopril tablets USP may be administered alone or with other antihypertensive agents
The treatment options for severe hypertension include:
- Monotherapy: using a single antihypertensive drug, such as doxazosin or lisinopril, to lower blood pressure.
- Combination therapy: using multiple antihypertensive drugs, such as doxazosin or lisinopril with other agents, to achieve blood pressure goals. These options may be used as part of comprehensive cardiovascular risk management, including lifestyle modifications and other therapies as needed 2 3.
From the Research
Treatment Options for Severe Hypertension
The treatment options for severe hypertension include various combination therapies, as most patients require more than one antihypertensive agent to achieve target blood pressure 4. The following are some of the treatment options:
- Combination therapy with separate agents or a fixed-dose combination pill to lower blood pressure more quickly and decrease adverse effects 4
- Diuretic therapy as the initial pharmacologic agent for most patients with hypertension, with the addition of other agents such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, or aldosterone antagonists for patients with heart failure 4
- Treatment with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, diuretics, beta blockers, or calcium channel blockers for hypertensive patients with diabetes 4
- Recommended treatment for hypertensive patients with increased risk of coronary disease includes a diuretic, beta blockers, angiotensin-converting enzyme inhibitors, and/or calcium channel blocker 4
Combination Therapy
Combination therapy is necessary in approximately 70% of hypertensive patients to achieve adequate blood pressure control 5, 6. The most effective combinations of antihypertensive drugs are those made with drugs that have a complementary effect on the blood pressure regulation systems 6. Some examples of combination therapy include:
- Angiotensin II receptor blockers (ARBs) or angiotensin-converting enzyme inhibitors (ACEIs) combined with calcium channel blockers (CCBs) and/or thiazide diuretics 7
- Fixed combinations of ACEIs or ARBs with CCBs and/or hydrochlorothiazide (HCTZ) 7
- Combination of ramipril and amlodipine, or candesartan and amlodipine, which represent a therapeutic opportunity of primary importance as they combine the ACE-inhibitor, AT1 antagonist, and the calcium channel blocker with the best documentation of efficacy in randomized controlled trials 6
Personalized Treatment
The choice of a combination therapy should not be limited only to evaluating the efficacy on blood pressure levels, but a more important target is certainly the ability to reduce cardiovascular events 6. The selection of a specific combination drug regimen has often been linked to the perceived need for diuretic therapy as first- or second-step therapy 8. However, rational alternatives exist, including an ACE inhibitor/calcium channel blocker (CCB) or a dihydropyridine CCB/b blocker combination 8.