COMMON SENSE TREATMENT OF HIGH BLOOD PRESSURE
Hypertension (high blood pressure) is a very common problem. I treated patients with high blood pressure every day, and many days, saw more patients with it than respiratory infections. The adverse consequences of HBP and the importance of keeping our BP normal are well known facts. Achieving control of BP is a challenge that requires patience, diligence, and adherence. Success can take weeks or even years, and the trial of multiple medications. It takes a persistent doctor, a cooperative patient, and a lot of experimentation.
Some fortunate people are able to control their BP simply by “lifestyle changes.” That means by losing weight, stopping smoking, exercising regularly, and reducing sodium in their diet, they are able to normalize their BP. The percentage of patients able to do this is very small, and the commitment required is beyond what most people can do.
Most patients, however, need to take medication to control BP. This is called pharmacotherapy. Most patients need one, two, three or more drugs to get their BP to the level experts say is ideal for prevention of complications. The number of anti-hypertensive drugs available today is incredible. Research in this area is constantly being conducted in the hope of finding more effective and safer drugs with the goal of reducing adverse effects while eliminating the long term complications of high blood pressure.
Drugs for treating HBP are divided into seven different groups which are classified by the mechanism of action they use to lower BP. Medical researchers and pharmaceutical companies have discovered seven different ways to interrupt the physiologic reaction that causes HBP.
The seven classes of blood pressure-lowering drugs are listed below. The more commonly used drugs within that class are listed, as well. Some drug names you may know. The drug classes are:
DIURETICS-drugs that reduce the volume of fluid within the blood vessels and relax the
smooth muscle in blood vessel walls. BP is lowered by these two mechanisms.
Drugs in this class: Thiazides (hydrochlorothiazide, chlorothiazide, chlorthalidone,
indapamide (Lozol ), metolazone (Zaroxolyn).
Loop diuretics (Bumex, Edecrin, Lasix, Demadex)—Rarely used to treat HBP
Potassium-sparing (spironolactone, triamterene)
Angiotensin is a protein produced by the liver. It is a potent vasoconstrictor—it makes blood vessels clamp down causing the blood pressure to be elevated.
ACE INHIBITORS (Angiotensin Converting Enzyme Inhibitors)—drugs that block the enzyme
that converts the potent BP-raising Angiotensin I to the more potent Angiotensin II.
Drugs in this class: lisinopril, ramipril, captopril, benazapril, enalapril, fosinopril, quinapril,
moexapril.
ARB (Angiotensin Receptor Blockers)—drugs that block Angiotensin from activating the blood
vessel receptors that elevate BP.
Drugs in this class: losartan, irbesartan, valsartan, candesartan, olmesartan, telmisartan,
Azilsartan, eprosartan.
CALCIUM CHANNEL BLOCKERS—drugs that block calcium from entering the cells in blood
vessel walls. Calcium makes blood vessels contract more strongly.
Drugs in this class: amlodipine, diltiazem, verapamil, isradipine, nicardipine, felodipine,
nifedipine, nisoldipine.
ALPHA ADRENERGIC RECEPTOR BLOCKERS-drugs that block the alpha receptors in the
sympathetic nervous system. This relaxes and dilates blood vessels.
Drugs in this class: prazosin, alfuzosin, doxazosin, tamsulosin, silodosin
BETA ADRENERGIC RECEPTOR BLOCKERS-drugs that block beta receptors in the
sympathetic nervous system which relax and dilate blood vessels.
Drug in this class: metoprolol, propranolol, atenolol, acebutalol, bisoprolol, nadolol,
nebivolol.
ALPHA 2 RECEPTOR AGONISTS-drugs that work in the brain and blood vessels to lower BP
Drugs in this class: clonidine, guanabenz, guanfacine, tizanidine, medetomidine,
dexmedetomadine
COMBINATION DRUGS-drugs of different classes are compounded together to reduce the
number of pills to take. Multiple combinations are available. Studies show better control
with 3-drug combinations.
OLDER DRUGS USED INFREQUENTLY-drugs that were used regularly but have fallen out of
favor due to adverse effects or limited efficacy.
Drugs: hydralazine, reserpine, alpha methyldopa
As you can see from the above, over 50 drugs are available for the treatment of HBP, and that doesn’t include the dozens of combination drugs on the market. Combination drugs were developed to simplify treatment and consolidate cost; two or three drugs are combined into one pill at one price. However, many combination drugs are not covered by insurance plans, and end up being more costly.
Drug treatment can be complicated. There is no set protocol for treating HBP, and treatment regimens (drug combinations) are individualized for each patient. The choice of drugs is based on the patient’s history and co-morbid diseases. Most people are controlled by one or two drugs, but some patients are on as many as five.
For decades, the “step care approach” was the standard of care. Every patient was started on a drug from a specified class of drugs, and the dosage was increased until side effects developed or the maximum dose was reached. If the BP was not then under control, a second drug was added from the next recommended drug class. It’s dosage was increased, also, until side effects occurred or the maximum dose was reached. Third, fourth, or even fifth drugs from different classes we’re added in a step-wise fashion until control was achieved.
This step-care protocol was devised by a panel of experts in HBP treatment (called the JNC—Joint National Commission). The commission recommended the use of this protocol for all HBP patients. The JNC met annually to update recommendations and change treatment when new drugs became available. They re-defined optimum levels for BP control and re-established abnormal BP levels.
The “step care” approach didn’t work for everybody, however. “Cookie cutter” regimens don’t fit all patients because some people have conditions that exclude certain drugs from use. Now, step care is used in a modified form tailored to the individual being treated. Certain drugs are “starter drugs” for just about everyone. Diuretics and ACE inhibitors are two examples. The starter drug dosage is increased gradually until control is achieved, side effects develop, or the maximum dose is reached. If BP control is not achieved, a second drug is added, but the choice is individualized. Thiazide diuretics raise blood sugar and uric acid so they should not be prescribed for diabetics and gout sufferers.
The patient’s blood pressure is monitored at home by the patient and in periodic visits to the doctor. One major treatment problem still exists, however. Despite being on medication, 30%-60% of patients never reach their blood pressure goal putting them at risk of the consequences of elevated blood pressure. HBP is asymptomatic so when patients don’t feel bad they don’t always remember to take their medications or check their BP with the regularity they should. Medication adherence is a big problem that contributes to high blood pressure being called “the silent killer.”
While taking medication, patients are still encouraged to lose weight, exercise, reduce salt intake and stop smoking. Compliance with every aspect of BP treatment is a never-ending battle for the patient and the doctor. Abundant data is available to show the the benefit of lowered BP, and patients need to repeatedly be reminded of these facts.
Dr. G’s Opinion: Blood pressure is one of the more important things physicians treat. There are so many benefits to having a normal BP, and so many tragic consequences from BP that is not controlled. The physician’s role is to provide proper guidance and supervise management to ensure that treatment is still working. This requires a willing patient and a committed doctor. Both need to work together toward the goal of effective control of BP. Prolonged good health depends on it.
References: Pio-Abreu A, Drager LF. Resistant hypertension: Time to consider the best fifth anti-hypertensive treatment. Curr Hypertension Rept Jun 16, 2018;67.
Dusing R, Waeber B, et al. Triple-combination therapy in the treatment of hypertension: a review of the evidence. J Hum Hypertension 2017 Feb 23;31:501-510.
Braam B, et al. Recognition and Management of Resistant Hypertension Clin J Am Soc Nephrol 2017 Mar 7; 12(3):524-535.
