Thiazide-type diuretics (chlorthalidone and indapamide) have been demonstrated to be superior in preventing cardiovascular disease at a lower cost. Recommendations are to start them as first-line treatment for hypertension.
Full Answer
What are the drug recommendations for the treatment of hypertension (high blood pressure)?
Recommendations are to start them as first-line treatment for hypertension. Multiple studies have shown that thiazide-like diuretics (chlorthalidone and indapamide) are more potent than hydrochlorothiazide in hypertension treatment. They are better at decreasing the risk of cardiovascular disease comparing to hydrochlorothiazide. [4] [5]
When should a second drug be added to treat high blood pressure?
Many people with mild high blood pressure respond to one medication. It may take a few tries to find the most effective drug. However, sometimes one drug cannot control high blood pressure. The doctor may increase the dose or change the medication, yet the blood pressure stays high. That's when a second drug may be added.
Should combination therapy be first-line treatment for hypertension?
Still, we feel that it does not detract from our plea in favor of the use of combination therapy as first-line treatment in most patients with hypertension. Although studies supporting the benefit of this compared to other strategies have limitations, this is also the case for other treatment strategies used in daily practice.
How to start antihypertensive therapy in treatment-naive hypertensive patients?
We proposed that starting antihypertensive therapy in treatment-naive hypertensive patients might be based on a few simple principles. First, use antihypertensive drugs with different modes of action in line with the AB/CD algorithm ( Figure 3 ).
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Keep Trying to Reach Your Blood Pressure Goal
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What is the best medication for hypertension?
Diuretics. There are three classes of diuretic drugs that are used to treat hypertension. Most commonly used are thiazide diuretics such as hydrochlorothiazide or chlorthalidone. There is not usually an increased urine flow after the first one or two days of taking these medications. Nevertheless, it is best to take them in ...
Why are ACEIs used for hypertension?
ACEIs are widely used to treat hypertension because they are effective, have relatively few side effects and in reduce the complications of hypertension such as heart attacks and strokes. They have a special use in patients with diabetes mellitus who have protein the urine (“diabetic nephropathy”) and in patients with chronic kidney disease (CKD) in whom they appeared to have beneficial actions in slowing the loss of kidney function above that achieved by other agents.
What is edecrin used for?
Ethacrinic acid (Edecrin) is used in the rare patients who are allergic to diuretics. Loop diuretics are not as effective as thiazides in lowering blood pressure in patients with hypertension. They are used especially to treat edema (swelling of the ankles) or heart failure.
Why are diuretics important?
Diuretics increase the effectiveness of all other categories of antihypertensives. That is why they are an essential part of almost any multidrug regimen for hypertension. Special Points: Diuretics are the original antihypertensives. Therefore, their efficacy and adverse effects are very well understood.
What is beta blocker?
BETA BLOCKERS, ALPHA BLOCKERS AND SYMPATHOLYTIC DRUGS. This group of drugs was introduced next after diuretics, to be used for hypertension. They act on a part of the nervous system that controls blood pressure, known as the sympathetic nervous system. Blockade of the sympathetic nervous system reduces blood pressure by relaxing blood vessels, ...
How often do you give captopril?
There are some small differences in how long these drugs act in the circulation, they are relatively small and, with the exception of the very short acting captopril, any of these agents are usually affective when given once or sometimes twice daily as antihypertensive agents.
Can diuretics cause low blood pressure?
Over treatment with diuretics can lead to low blood pressure , orthostatic hypotension (weakness, dizziness and possibly fainting on standing) and a feeling of tiredness and lethargy, all of which can be prevented or reversed by holding the diuretic for a day or two and resuming, if necessary, at a lower dosage.
What is the best way to reduce blood pressure?
Diuretics . Diuretics , sometimes called water pills, help the kidneys get rid of excess water and salt (sodium). This reduces the volume of blood that needs to pass through the blood vessels. As a result, blood pressure goes down. There are three major types of diuretics defined by how they work.
What is resistant hypertension?
Resistant hypertension refers to blood pressure that remains high after trying at least three different types of blood pressure medication. Someone whose high blood pressure is controlled by taking four different kinds of medication is considered to have resistant hypertension.
How does catecholamine affect blood pressure?
The muscles around some blood vessels have what are known as alpha-1 or alpha adrenergic receptors. When a catecholamine binds to an alpha-1 receptor, the muscle contracts, the blood vessel narrows, and blood pressure rises.
How to make the most of your treatment?
To make the most of your treatment, it’s vital to get regular medical checkups and blood pressure tests. Regular checkups allow your doctor to monitor how well your treatment is going and make any necessary adjustments to your treatment plan.
What is considered high blood pressure?
The goal is to get your blood pressure below the high range. If normal is less than 120/80 mm Hg, what’s high? When the systolic blood pressure — the top number — is between 120 and 129, and the diastolic blood pressure — the bottom number — is less than 80, this is considered elevated blood pressure.
How does ACE inhibitor work?
ACE inhibitors help the body produce less of a hormone called angiotensin II, which causes blood vessels to narrow. These medications decrease blood pressure by helping blood vessels expand and let more blood through.
What is the purpose of calcium channel blockers?
Calcium channel blockers limit calcium from entering the smooth muscle cells of the heart and blood vessels. This makes the heart beat less forcefully with each beat and helps blood vessels relax.
What are some examples of blood pressure medications?
Examples are spironolactone (Aldactone, Carospir) and eplerenone (Inspra). How well a drug works for you can depend on your age, sex, race, blood pressure level and overall health.
What are some examples of medications that can cause high blood pressure?
Examples include hydralazine and minoxidil. Aldosterone antagonists. These medications are often used with other drugs, such as a diuretic. Aldosterone antagonists block the hormone aldosterone, which sometimes causes salt and fluid retention, contributing to high blood pressure.
What are some examples of ACE inhibitors?
There are several ACE inhibitors available. Examples include enalapril (Vasotec, Epaned), lisinopril (Prinivil, Zestril, Qbrelis) and ramipril (Altace). Angiotensin II receptor blockers (ARBs). These drugs block the action of angiotensin, a chemical in your body that narrows your arteries and veins.
What are some examples of beta blockers?
Examples of beta blockers include metoprolol (Lopressor, Toprol-XL), nadolol (Corgard) and atenolol (Tenormin). Renin inhibitors. Renin is a substance produced by your kidneys that triggers a series of steps that increases blood pressure.
What are some examples of calcium channel blockers?
Examples of calcium channel blockers include amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others), nifedipine (Adalat CC, Procardia) and verapamil (Verelan, Calan). Beta blockers. These drugs work by blocking the effects of the hormone epinephrine, also known as adrenaline.
What are the different types of diuretics?
There are three types of diuretics: thiazide, loop and potassium-sparing. Examples of diuretics include chlorothiazide (Diuril), bumetanide (Bumex) and amiloride (Midamor). If diuretics aren't enough to lower your blood pressure, your doctor might recommend adding other blood pressure medications to your treatment.
How well do drugs work?
How well a drug works for you can depend on your age, sex, race, blood pressure level and overall health. Combining two drugs usually works better than a single drug to get your blood pressure under control. Sometimes additional medication is needed to achieve your blood pressure goal.
What is the most common modifiable risk factor for cardiovascular disease and death?
New approaches in the treatment of hypertension. Hypertension is the most common modifiable risk factor for cardiovascular disease and death, and lowering blood pressure with antihypertensive drugs reduces target organ damage and prevents cardiovascular disease outcomes.
Is hypertension a risk factor for cardiovascular disease?
Hypertension is the most common modifiable risk factor for cardiovascular disease and death, and lowering blood pressure with antihypertensive drugs reduces target organ damage and prevents cardiovascular disease outcomes. Despite a plethora of available treatment options, a substantial portion of the hypertensive population has uncontrolled blood ...
What is the target BP for kidney disease?
In patients with chronic kidney disease, the target BP is 130/80. For patients with type 2 diabetes mellitus (T2DM), it is recommended to start on antihypertensive medications if BP is more than 130/80 with a goal of BP lower than 130/80.
What is the HTN stage?
The 2017 American College of Cardiology (ACC) and American Heart Association (AHA) definition of HTN stages is: Normal blood pressure (BP): systolic BP is less than 120, and diastolic BP is less than 80. Elevated BP: systolic BP 120 to 130 ...
Which is better, chlorthalidone or doxazosin mesylate?
Chlorthalidone, when compared with doxazosin mesylate, was better in preventing cardiovascular disease, when compared with lisinopril was found to be better in preventing cardiovascular disease, including strokes and heart failure incidence, and when compared with amlodipine was better in preventing heart failure.
How do beta blockers work?
Beta-blockers work by inhibiting the catecholamines from binding to the Beta 1,2, and 3 receptors. Beta-1 receptors are found primarily in the heart muscle, beta-2 receptors are located in the bronchial and peripheral vascular smooth muscles, and beta-3 receptors appear in adipose tissue of the heart.
Does hydrochlorothiazide lower blood pressure?
Switching to chlorthalidone from hydrochlorothiazide decreases systolic blood pressure by 7 to 8 mm Hg.
Is chlorthalidone better than hydrochlorothiazide?
They are better at decreasing the risk of cardiovascular disease comparing to hydrochlorothiazide. [4][5] Chlorthalidone is the drug of choice to start as monotherapy for hypertension. Studies show it to be the best diuretic to control blood pressure and to prevent mortality and morbidity.
Is spironolactone a good antihypertensive?
Spironolactone is superior to doxazosin and bisoprolol in lowering blood pressure when added to first-line antihypertensive agents in treating resistant hypertension. [28] Hydralazine can be added for the treatment of resistant hypertension, either alone or in combination with nitrates, in case of heart failure.
What is combination therapy for high blood pressure?
Combination treatment means another class of blood pressure medication is added to the first drug to increase effectiveness. Many people with mild high blood pressure respond to one medication. It may take a few tries to find the most effective drug. However, sometimes one drug cannot control high blood pressure.
How does angiotensin help lower blood pressure?
They help lower blood pressure by inhibiting the production of angiotensin in the body. Angiotensin is a hormone that causes blood vessels to constrict which can lead to increased blood pressure. Angiotensin II receptor blockers (ARBs): The ARBs block the effects of angiotensin.
What is resistant hypertension?
Resistant hypertension means blood pressure that stays high despite treatment with three different types of blood pressure medications. It's thought that about 30% of people with high blood pressure have resistant hypertension.
What are the risk factors for resistant hypertension?
Other studies suggest that people with resistant hypertension have associated risks factors such as diabetes, obstructive sleep apnea, enlargement of the heart chambers, and or chronic kidney disease.
Can you use thiazide alone?
Sometimes, using lower doses of one or more drugs in combination can minimize side effects. Thiazide diuretics may be used alone to treat hypertension. Low-dose diuretics, though, can also be used with other medications such as beta-blockers. When used in a drug combination, the diuretic has fewer side effects.
Can a diuretic be used in combination with a blood pressure medication?
When used in a drug combination, the diuretic has fewer side effects. It also boosts the blood-pressure-lowering effect of the other medication. Diuretics are added to other blood pressure medications. For instance, if the person with high blood pressure also retains fluid, a diuretic may be added.
Is combination therapy for hypertension individualized?
Combination treatment for hypertension is individualized. It gives the best possible control of blood pressure with the fewest side effects. Also, combination treatment may cost less. There may be less frequent doctor visits as the drug combination effectively manages the hypertension.
Who is the first author of the paper "The First Line of Treatment for Hypertension"?
A new paper — the first author of which is Dr. Marc A. Suchard, from the department of biostatistics at the University of California, Los Angeles — showcases some of the pitfalls behind deciding which is the best first line of treatment for hypertension.
Which first line drug has more side effects than thiazide?
The study revealed that angiotensin converting enzyme (ACE) inhibitors, which are the most commonly prescribed first-line drugs, had more side effects than thiazide diuretics, a class of drugs that are not prescribed as often.
Which organization has based their guidelines on randomized clinical trials?
First, the existing literature that organizations such as the American College of Cardiology and the American Heart Association (AHA) have based their guidelines on are randomized clinical trials with an insufficient number of participants, very few of whom are just beginning their treatment, explain Dr. Suchard and colleagues.
Treatment
- There are three classes of diuretic drugs that are used to treat hypertension. Most commonly used are thiazide diuretics such as hydrochlorothiazide or chlorthalidone. There is not usually an increased urine flow after the first one or two days of taking these medications. Nevertheless, it is best to take them in the morning to prevent annoying uri...
Interactions
- Diuretics increase the effectiveness or all other classes of antihypertensive agents. Therefore, almost any subject, except those with a contraindication, should receive a diuretic if their blood pressure requires more than one drug for its management.
Adverse effects
- Adverse Effects: Diuretics increase the excretion of potassium and can lead to hypokalemia (low blood potassium concentration) which predisposes to irregular heart beats, and muscular weakness. However, a combination of a thiazide or loop diuretic with a distal, potassium sparing agent (such as in the combined medications, Maxzide or Moduretic), prevents potassium loss a…
Types
- Different Drugs: Thiazide diuretics include: hydrochlorothiazide (usual starting dose 12.5 to 25 mg daily) or chlorthalidone (similar dose range). Loop diuretics include: furosemide (Lasix), bumetanide (Bumex), and torsemide (Demadex), torsemide has a rather longer duration and is preferred in patients with heart failure. Ethacrinic acid (Edecrin) is used in the rare patients who …
Medical uses
- ACEIs are widely used to treat hypertension because they are effective, have relatively few side effects and in reduce the complications of hypertension such as heart attacks and strokes. They have a special use in patients with diabetes mellitus who have protein the urine (diabetic nephropathy) and in patients with chronic kidney disease (CKD) in whom they appeared to have …
Examples
- Individual Drugs: The following are examples of ACEIs in clinical practice: benazepril (Mylan), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), Lisinopril (Prinivil), moexipril (Univasc), quinapril (Accupril), ramipril (Altace) and trandolapril (Mavik). There are some small differences in how long these drugs act in the circulation, they are relatively small and, with the e…
Side effects
- Biochemical changes with ACEIs are usually insignificant in patients with normal kidney function. However, in those with impaired kidneys, they can raise the serum potassium concentration to levels that are dangerous and require either a change in therapy, or increasing thiazide or loop diuretic dosage to promote potassium loss. Such patients should discuss with their physician o…
Contraindications
- Special Indications: As these include patients with chronic kidney disease (but see the adverse effects above), early diabetes mellitus, congestive heart failure, or left ventricular hypertrophy. These drugs will not be discussed in detail since they are used infrequently.
Mechanism of action
- This group of drugs was introduced next after diuretics, to be used for hypertension. They act on a part of the nervous system that controls blood pressure, known as the sympathetic nervous system. Blockade of the sympathetic nervous system reduces blood pressure by relaxing blood vessels, and decreasing the rate and force of contraction of the heart. Therefore, beta blockers a…
Pharmacology
- The actions of these agents are enhanced in patients taking diuretic drugs and therefore are a good second or third line selection in those patients who are not controlled with a diuretic and an ACEI or ARB. Unfortunately, alpha blockers have been shown to be less affective than other groups of blood pressure lowering agents in preventing the complications of heart failure and he…
Categories
- Individual drugs: They fall into two categories. The first are called dihydropyridine CCBs and include amlodipine (Norvasc), felodipine (Plendil), nifedipine (Procardia), and nicardipine (Cardene). The second, termed nondihydropyridine CCBs include two drugs, diltiazem (Dilacor, Cardizem, Cartia, and Tiazac), and verapamil (Calan, Covera, Isoptin, Verelan). Both groups are e…
Effects
- Non-dihydropyridine CCBs cause cardiac slowing. This typically reduces the heart rate by about 10%. It can be beneficial in some patients with a fast heart rate or who have irregular heartbeat (atrial fibrillation), but in those with a slow initial heart rate, it can cause symptoms of decreased cardiac output (tiredness, lethargy, and dizziness on exertion). This group of drugs also can cau…
Research
- This is a rapidly developing field with extensive research, both by Centre scientists in the laboratory and clinical investigators in patients with hypertension. The following outlines some of the areas of research conducted at the Centre at Georgetown. Research at the Hypertension, Kidney and Vascular Research Centre at Georgetown has focused on a different path, namely dr…
Pathophysiology
- Oxidative stress occurs in cells and tissues of the body when oxygen reacts to form toxic molecules called reactive oxygen species (ROS). These can inactivate the normal signaling pathways between cells, damage cell membranes and proteins, and alter the DNA that forms the basis of our genes. Therefore, oxidative stress has widespread effects in the body. Increasing ev…
Cause
- Amongst those factors that are under our control which influence the probability of developing hypertension, an excessive dietary salt intake is probably the most important. Research in animal models at Georgetown at the Center for Hypertension, Kidney, and Vascular Research has linked dietary salt intake with oxidative stress that may underlie the hypertension and adverse consequ…
Resources
- For further information about how to support the research in Georgetown Universitys Center for Hypertension, Kidney, and Vascular Research, please see Georgetown Universitys Office of Advancement.