Goal of Therapy
There are three goals you aim to achieve by treating hypertension. What are they?
- Reduction of cardiovascular and renal morbidity and mortality.
- Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.
- Achieve SBP goal especially in persons >50 years of age.
Special Considerations of Therapy
Audio of Algorithm of Treatment for Hypertension (Running Time :54)
Increasing Titration of Medications
- Start the initial blood pressure medication at the recommended starting dose.
- Continue to titrate the dose in upward increments until you have achieved blood pressure control or you have reached a maximum dose of the drug.
- If you have not achieved blood pressure control at a maximum dose of the initial drug, begin adding another agent from another class and titrate up until the blood pressure is optimal.
- If you have not achieved blood pressure control at maximum doses of the combination of medications, continue adding agents from other classes.
- Remember that most hypertensive patients will require two or more medications to optimize their blood pressure.
What defines maximum dose for patients?
- This may be the maximum allowed dose of a drug as set by a pharmaceutical manufacturer or federal drug enforcement agency. An example is metoprolol whose initial starting dose is 25 – 50mg/day and the maximum allowed dose is 400mg/day.
- The maximum dose may be determined by the drug’s side effect profile. Metoprolol may have a maximum allowed dose of 400mg/day, however if the patient’s pulse is 58 at a metoprolol dose of 50 mg/day – then that is the maximum dose for the patient due to bradycardia.
- The maximum dose may also be determined by patient preference. A patient may refuse to take sustained release nifedipine at 90 mg/day because the 90mg pills are too large. They may agree to take the smaller 60mg pill.
- It is important to cite in your clinical notes why a patient has achieved a maximum dose of an anti-hypertensive drug.
Expense and Patient Convenience
- Generic drugs reduce costs to patients, institutions, and society as a whole. Generic drugs are as effective as their brand name counterparts. An example is generic lisinopril which costs approximately $18.99 a month for a 30 day supply of 5mg tablets. A brand name version of lisinopril costs approximately $34.58 a month for a 30 day supply of 5mg tablets.
- Use 24 hour formulations of medications whenever possible. These formulations allow 50% of the medication to still be in the system 24 hours later, and keep drug levels and blood pressures levels that are constant all day. Patients also prefer taking a one a day drug over those that are taken several times a day.
- Consider combination medications when a patient has achieved blood pressure control with separate medications. For example, a patient with excellent blood pressure control on losartan 100mg/day and hydrochlorathiazide 25mg/day will have a reduced pill burden with one combination pill a day of losartan/hydrochlorathiazide 100mg/25mg a day.
Tobacco
- Nicotine increases blood pressure and reduces the efficacy of blood pressure medications
- Hypertensive patients should be vigorously encouraged towards smoking reduction and cessation at every visit by their physicians.
Mary Johnson and Her Initial Treatment Plan
We return to your patient, Mary Johnson, a 39 year old African American, non-smoking female recently diagnosed with asymptomatic Stage 1 Hypertension. Her initial laboratory tests were all within normal limits. You have counseled her on lifestyle modifications and are now ready to start drug therapy.
What would you recommend as initial drug treatment in Mary Johnson?
After you answer this question, you will again have the ability to see the results of all those brave souls who have gone ahead and answered this question before you.
We return to your patient, Mary Johnson, a 39 year old African American, non-smoking female recently diagnosed with asymptomatic Stage 1 Hypertension. Her initial laboratory tests were all within normal limits. You have counseled her on lifestyle modifications and are now ready to start drug therapy.
What would you recommend as initial drug treatment in Mary Johnson? (Choose the one best answer)
The correct answer is B. - Thiazide diuretic. Mary Johnson is a Stage 1 hypertension patient without compelling indications thus the initial drug of choice is a thiazide diuretic for most. She should be told to take the medication in the morning and that she will urinate a lot more than prior. This is a normal effect of a diuretic and this will help in reducing her blood pressure.
Follow Up and Monitoring
- Patients should return for monthly follow up and adjustment of medications until the BP goal is reached.
- More frequent visits for stage 2 hypertension or with complicating co-morbid conditions.
- Serum potassium and creatinine should be monitored 1–2 times per year.
- After blood pressure is at goal and stable, follow up visits at 3- to 6-month intervals.
- Although not mentioned in JNC 7, consideration should be given to periodic rechecking fasting cholesterol panels and glucose, and possibly urine microalbumin if initial surveillance was negative.
Move on to Part 3 of this module