Prichard's Regimen for Hypertension Management
Prichard's regimen refers to the combination of a beta-blocker (nadolol) with a thiazide diuretic (bendroflumethiazide) for hypertension treatment, but this approach is now outdated and should NOT be used as first-line therapy for uncomplicated hypertension in adults. 1
Why Prichard's Regimen Is Not Recommended
Beta-blockers are no longer first-line agents for uncomplicated hypertension and should only be combined with other antihypertensive classes when compelling indications exist, such as angina, post-myocardial infarction, heart failure with reduced ejection fraction, or heart rate control needs. 1
The fixed-dose combination of nadolol and bendroflumethiazide is specifically not indicated for initial therapy of hypertension according to FDA labeling. 2
ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazide/thiazide-like diuretics have demonstrated the most effective reduction of blood pressure and cardiovascular events, making them the recommended first-line treatments. 1
Current Evidence-Based Approach Instead
For Stage 1 Hypertension (BP 140-159/90-99 mmHg)
Start with combination therapy using a RAS blocker (ACE inhibitor or ARB) plus either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic as a single-pill combination. 1
Preferred thiazide-like diuretics are chlorthalidone (12.5-25 mg daily) or indapamide (1.25-2.5 mg daily), which have superior cardiovascular event reduction compared to hydrochlorothiazide. 3, 4
For Stage 2 Hypertension (BP ≥160/100 mmHg)
Immediately initiate two-drug combination therapy with a RAS blocker plus a thiazide/thiazide-like diuretic or calcium channel blocker, preferably as a single-pill combination. 3, 5
If blood pressure remains uncontrolled after 2-4 weeks at optimal doses, escalate to triple therapy by adding a dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily). 3
Blood Pressure Targets
Target systolic BP of 120-129 mmHg in most adults if well tolerated to reduce cardiovascular risk. 1, 3
If this target cannot be achieved due to poor tolerance, apply the "as low as reasonably achievable" (ALARA) principle. 1
Critical Pitfalls to Avoid
Never use beta-blocker monotherapy or beta-blocker combinations as first-line treatment for uncomplicated hypertension, as they lack the cardiovascular mortality benefit demonstrated by thiazide diuretics and ACE inhibitors. 1, 4
Do not start with monotherapy in patients with confirmed hypertension ≥140/90 mmHg, as combination therapy provides more effective blood pressure control and faster achievement of targets. 1, 6
Never combine two RAS blockers (ACE inhibitor plus ARB), as this increases adverse events without additional cardiovascular benefit. 1, 3
When Beta-Blockers Are Appropriate
Reserve beta-blockers for patients with compelling indications: post-myocardial infarction, angina pectoris, heart failure with reduced ejection fraction, or atrial fibrillation requiring rate control. 1, 3
In these cases, combine the beta-blocker with a RAS blocker, thiazide diuretic, or calcium channel blocker—not as monotherapy. 1