Can You Discontinue Antihypertensives After Starting Them?
No, you should not expect to discontinue antihypertensive medications once started—hypertension treatment is generally lifelong, and cessation of therapy almost always results in blood pressure returning to pre-treatment levels. 1
Why Antihypertensive Therapy Is Typically Permanent
- Hypertension is a chronic condition that requires ongoing management rather than a temporary intervention. 1
- Stopping antihypertensive drugs leads to BP rebound in the vast majority of patients, returning blood pressure to hypertensive levels within weeks to months. 1
- The underlying pathophysiology (vascular resistance, arterial stiffness, neurohormonal dysregulation) persists even when BP is controlled with medication. 2
The Critical Role of Lifestyle Modification
While medication discontinuation is unrealistic, aggressive lifestyle changes can reduce your medication burden or delay the need to start drugs:
- Weight loss is the most powerful non-pharmacologic intervention for hypertension in obese patients—every 1 kg of weight loss reduces systolic BP by approximately 1 mmHg. 2
- Dietary sodium restriction to <2 g/day and potassium supplementation (through diet, not supplements) can lower BP by 5-10 mmHg. 2
- Regular aerobic exercise (150 minutes/week) reduces systolic BP by 5-8 mmHg independent of weight loss. 2
- Limiting alcohol consumption (≤2 drinks/day for men) provides additional BP reduction of 2-4 mmHg. 2
When to Start Antihypertensive Drugs
Do not self-initiate antihypertensive therapy—proper diagnosis and risk stratification by a physician are essential:
- Stage 1 hypertension (140-159/90-99 mmHg): Start lifestyle interventions immediately; begin drug therapy only if you have high cardiovascular risk (diabetes, chronic kidney disease, cardiovascular disease, or age 50-80 years) or if BP remains elevated after 3-6 months of lifestyle changes. 1
- Stage 2 hypertension (≥160/100 mmHg): Start drug treatment immediately alongside lifestyle interventions. 1
- For a 39-year-old obese Asian man without other risk factors, you would typically trial lifestyle modifications for 3-6 months before starting medication if your BP is in the stage 1 range. 1
The Correct First-Line Drug Choice
If medication becomes necessary, the first-line agent should be a thiazide diuretic (chlorthalidone 12.5-25 mg or hydrochlorothiazide 12.5-25 mg daily), not a combination product like Lotrel:
- Thiazide diuretics have the strongest evidence for reducing cardiovascular mortality and stroke in hypertensive patients. 3, 2, 4, 5
- Combination therapy (like Lotrel) should never be used as initial treatment—it is reserved for patients who fail to achieve BP control on a single agent. 3
- For non-Black patients under 55 years, an ACE inhibitor or ARB is an acceptable alternative to a thiazide diuretic as first-line therapy. 1
Realistic Expectations for Long-Term Management
- BP control requires lifelong medication in >95% of patients who start antihypertensive therapy. 1
- Successful lifestyle modification may allow dose reduction (not discontinuation) in some patients who achieve sustained weight loss and maintain healthy habits. 6
- The goal is BP <130/80 mmHg for adults under 65 years with confirmed hypertension. 3, 2
- Medication adherence is critical—non-adherence is the most common cause of apparent treatment failure. 7
Common Pitfalls to Avoid
- Do not self-prescribe antihypertensives without proper BP confirmation using home or ambulatory monitoring—office readings can overestimate true BP (white coat hypertension). 1
- Do not start with combination therapy—single-agent therapy allows you to identify which drug class works best and minimizes side effects. 3
- Do not expect to "cure" hypertension with medication—the goal is control, not cure, and this requires ongoing treatment. 1
- Do not neglect lifestyle changes even if you start medication—they enhance drug efficacy and may allow lower doses. 2