Antihypertensive Selection

Aka: Antihypertensive Selection, Hypertension Monotherapy

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II. Protocol: Step 1 (Determine when and how to intervene)

  1. Review Hypertension Risk Stratification
  2. Determine Hypertension Reduction Goal

III. Protocol: Step 2

  1. Consider Hypertension Combination Therapy
    1. For Refractory Hypertensive Populations
    2. Combination therapy to start appears to be more effective than starting with monotherapy
  2. Choose agents first based on comorbidity and cohort
    1. See Hypertension Management for Specific Comorbid Diseases
    2. See Hypertension Management for Specific Populations
  3. Monotherapy (when not otherwise directed by comorbidity or cohort)
    1. Consider starting with combination tablet Lisinopril/Hctz 20/25 mg (Kaiser-Permanante)
      1. http://providers.kaiserpermanente.org/info_assets/cpp_cod/cod_adult_bp_clinician_guide.pdf
      2. Allows for dosing at 1/2 tablet (10/12.5 mg), 1 tablet, or 2 tablets (40/50 mg)
    2. Standard initial monotherapy choices
      1. Thiazide Diuretics (e.g. Hydrochlorothiazide)
        1. Hydrochlorothiazide 12.5 to 25 mg orally daily
        2. Chlorthalidone 12.5 to 25 mg orally daily
        3. Efficacy
          1. If Diuretic is not first, it should be second
          2. Excellent adjunct to other Antihypertensives
          3. Better outcomes than Lisinopril and Amlodipine
            1. Reduced risk of CVA, MI, CHF over other agents
            2. (2002) JAMA 288:2981-97 [PubMed]
      2. ACE Inhibitor or Angiotensin Receptor Blocker (ARB)
        1. Preferred first-line agent in age under 60 years old, Chronic Kidney Disease, Diabetes Mellitus
        2. Lisinopril 5 to 40 mg orally daily
        3. Losartan (Cozaar) 25 to 100 mg orally daily
      3. Long-acting Dihydropyridine Calcium Channel Blocker
        1. Amlodipine (Norvasc) 2.5 to 5 mg orally daily
    3. Compelling reason for other Antihypertensive
      1. See AntiHypertensives for Specific Comorbid Diseases
      2. See Antihypertensives for Specific Populations
    4. Agents to avoid for monotherapy
      1. Alpha blockers
      2. Hydralazine
      3. Minoxidil
      4. Beta Blocker
        1. Trend is to avoid Beta Blockers as first-line agents in uncomplicated Hypertension
        2. Reserve for patients with Coronary Artery Disease or Congestive Heart Failure
    5. Avoid if non-compliant (rebound Hypertension risk)
      1. Beta Blockers
      2. Clonidine

IV. Protocol: Step 3

  1. Consider Hypertension Combination Therapy
  2. Consider starting two agents when Blood Pressure >20/10 above goal

V. Metabolism: Antihypertensives not affected by Cytochrome P450 system

  1. Angiotensin Receptor Blockers
    1. Valsartan
    2. Eprosartan
    3. Candesartan
  2. Diuretics
    1. Hydrochlorothiazide
    2. Furosemide
  3. Alpha-adrenergic agents
    1. Prazosin
    2. Clonidine

VI. References

  1. Clarke (2023) Am Fam Physician 108(3): 352-9 [PubMed]

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