Learning objectives
- Therapeutic uses of Antihypertensives
- Contraindications
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Introduction
Diagnosis and management of BP is well documented by the NICE guidelines published in 2001 Here.
- Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
- Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
- Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.
Classes Used and abbreviations
- Angiotensin-converting enzyme (ACE) inhibitor
- Angiotensin-II receptor blocker (ARB)
- Calcium channel blocker (CCB)
- Thiazide Like Diuretic (TZD)
- Loop diuretic (LD)
- Beta Blockers (BB)
Pharmacology of Common Antihypertensives
| Name and BNF link | Class | Dose | Side effects | Notes |
|---|
| Indapamide | TZD | 1.5 mg modified-release once daily or 2.5 mg once daily | Side effects | Notes |
| Ramipril | ACEI | Start 1.25–2.5 mg OD, increased if necessary up to 10 mg once daily, dose to be increased at intervals of 2–4 weeks | Side effects | Notes |
| Name and BNF link | Class | Dose | Side effects | Notes |
| Name and BNF link | Class | Dose | Side effects | Notes |
| Name and BNF link | Class | Dose | Side effects | Notes |
Evidence base
Patients under 55 years:
- Step 1: ACEI; if not tolerated, offer an ARB. If both ACEI and ARB are contra-indicated or not tolerated, consider a BB; BB, especially when combined with a TZD, should be avoided for the routine treatment of uncomplicated hypertension in patients with diabetes or at high risk of developing diabetes
- Step 2: ACEI or ARB in combination with a CCB. If a CCB is not tolerated or if there is evidence of, or a high risk of, heart failure, give a TZD (e.g. chlortalidone or indapamide). If a BB was given at Step 1, add a CCB in preference to a TZD (see Step 1)
- Step 3: ACEI or ARB in combination with a CCB and a TZD
- Step 4 (resistant hypertension): Consider seeking specialist advice
- Add low-dose spironolactone [unlicensed indication], or use high-dose TZD if plasma-potassium concentration above 4.5 mmol/litre
- Monitor renal function and electrolytes
If additional diuretic therapy is contra-indicated, ineffective, or not tolerated, consider an alpha-blocker or a beta-blocker
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Patients over 55 years, and patients of any age who are of African or Caribbean family origin:
- Step 1: CCB; if not tolerated or if there is evidence of, or a high risk of, heart failure, give a TZD (e.g. chlortalidone or indapamide)
- Step 2: CCB or TZD in combination with an ACEI or ARB (an ARB in combination with a CCB is preferred in patients of African or Caribbean family origin)
- Steps 3 and 4: Treat as for patients under 55 years. Cardiovascular risk reduction.
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