What are the alternative management strategies for hypertension when Amlodipine (calcium channel blocker) and Diuretics are contraindicated?

From the Guidelines

When managing hypertension in patients where amlodipine and diuretics are contraindicated, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are recommended as first-line alternatives, as per the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The major four drug classes, including ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics, are recommended as first-line BP-lowering medications, either alone or in combination. However, in the absence of amlodipine and diuretics, ACE inhibitors or ARBs can be used as alternatives. Examples include lisinopril (starting at 10mg daily, maximum 40mg) or losartan (starting at 50mg daily, maximum 100mg). Some key points to consider when managing hypertension in these patients include:

• Starting with low-dose combination therapy, which can have additive or synergistic effects and lead to greater BP reduction than increasing the dose of one drug 1.
• Using single-pill combinations, which are preferred over separate pills, to improve adherence and persistence 1.
• Considering the patient's individual response to different BP-lowering drug classes, as well as their race and ethnicity 1.
• Monitoring blood pressure, renal function, and electrolytes regularly, especially when initiating new medications or adjusting doses.
• Lifestyle modifications, including sodium restriction, weight management, regular exercise, and limiting alcohol consumption, remain essential components of any hypertension management plan. In cases where blood pressure remains uncontrolled despite maximally tolerated triple-combination therapy, the addition of spironolactone or other mineralocorticoid receptor antagonists (MRAs) should be considered, as per the 2020 International Society of Hypertension global hypertension practice guidelines 1. However, the most recent and highest quality study, the 2024 ESC guidelines, recommends considering the addition of spironolactone, eplerenone, or other MRAs, or beta-blockers, as fourth-line treatment for BP lowering 1.

From the Research

Management of Hypertension Without Amlodipine and Diuretics

• When amlodipine and diuretics are contraindicated, alternative treatments for hypertension can be considered, including angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) 2, 3.
• Studies have shown that ACEIs and ARBs have comparable efficacy in lowering blood pressure, but ARBs are generally better tolerated and have fewer adverse effects, such as cough and angioedema 2, 4.
• A systematic review of 10 articles examining 1,621,445 patients found that both ACEIs and ARBs are effective in lowering blood pressure, but ACEIs may be superior in reducing cardiovascular events and all-cause mortality 5.
• However, ARBs are often preferred due to their better tolerability and lower risk of adverse effects, making them a suitable alternative for patients who cannot take amlodipine or diuretics 3, 4.

Alternative Treatment Options

• Losartan, an ARB, has been shown to have a similar antihypertensive effect to amlodipine and lisinopril, but with superior tolerability 4.
• Other ARBs, such as valsartan and candesartan, may also be considered as alternative treatment options for patients with hypertension who cannot take amlodipine or diuretics 3.
• The choice of alternative treatment should be based on individual patient characteristics, medical history, and comorbidities, as well as the presence of any contraindications or potential drug interactions 2, 5.

Considerations for Treatment

• When selecting an alternative treatment for hypertension, it is essential to consider the patient's overall health status, including the presence of any comorbidities, such as kidney disease or heart failure 3, 5.
• The treatment plan should be individualized and monitored regularly to ensure that blood pressure goals are being met and to minimize the risk of adverse effects 2, 4.
• Lifestyle modifications, such as dietary changes and increased physical activity, should also be encouraged to help manage hypertension and reduce the risk of cardiovascular disease 3, 5.