Hypertension Medicine Selection

Hypertension medicine selection matches the drug class to the person’s compelling conditions, ancestry, age, kidney function, pregnancy potential and comorbid disease, because the main classes lower pressure to a similar degree and most outcome benefit comes from the lowering itself. Diagnosis is confirmed by clinic readings of 140/90 mmHg or over together with a home or ambulatory average of 135/85 mmHg or over.

Four classes form the base: ACE inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers and thiazide-like diuretics. Beta blockers are used for specific indications.

Targets. Aim for under 140/90 mmHg in all adults and under 130/80 mmHg when tolerated in adults under 80 years. At age 80 or over, aim for under 150/90 mmHg, accepting a systolic pressure of 140 to 150 mmHg in frailty.

Baseline assessment. Record creatinine and eGFR, potassium, sodium, urine albumin to creatinine ratio, glucose or HbA1c, lipids, ECG, pregnancy status and use of NSAIDs, decongestants, liquorice, khat or oestrogen-containing products.

Ancestry. In people of African ancestry, calcium channel blockers and thiazide-like diuretics lower pressure more than an ACE inhibitor or angiotensin receptor blocker used alone. ACE inhibitor cough and angioedema are also more frequent.

Class	Usual regimen	Preferred when	Avoid or use with caution
ACE inhibitor	Ramipril 2.5 mg orally once daily, increase every 2 to 4 weeks to 10 mg daily	Heart failure, after myocardial infarction, diabetes or chronic kidney disease with albuminuria	Pregnancy, angioedema, bilateral renal artery stenosis, potassium over 5.5 mmol/L
Angiotensin receptor blocker	Losartan 50 mg orally once daily, maximum 100 mg daily; candesartan 8 mg once daily, maximum 32 mg	Same indications; ACE inhibitor cough	Pregnancy, potassium over 5.5 mmol/L
Dihydropyridine calcium channel blocker	Amlodipine 5 mg orally once daily, maximum 10 mg daily	African ancestry, older adults, angina, isolated systolic hypertension	Ankle oedema; avoid short-acting nifedipine
Thiazide-like diuretic	Indapamide modified-release 1.5 mg orally once daily; chlorthalidone 12.5 mg once daily, usual maximum 25 mg	Older adults, African ancestry, isolated systolic hypertension	Gout, hyponatraemia, hypokalaemia
Beta blocker	Bisoprolol 2.5 mg orally once daily, maximum 10 mg daily	Angina, after myocardial infarction, heart failure, atrial fibrillation rate control	Asthma, heart block, bradycardia; weaker stroke protection
Mineralocorticoid receptor antagonist	Spironolactone 25 mg orally once daily	Later add-on and resistant hypertension	Potassium over 5.0 mmol/L, eGFR under 30 mL/min/1.73 m2
Alpha blocker	Doxazosin 1 mg orally at night, titrated to 4 mg, maximum 16 mg daily	Add-on, prostatic symptoms	Postural hypotension, falls

Compelling conditions. In heart failure with reduced ejection fraction use the heart failure drugs. In gout choose losartan or a calcium channel blocker rather than a thiazide-like diuretic. In asthma avoid non-selective beta blockers. In women who may become pregnant avoid ACE inhibitors and angiotensin receptor blockers unless contraception is reliable.

Special groups. Older adults start at half dose, for example amlodipine 2.5 mg or ramipril 1.25 mg. In chronic kidney disease with creatinine clearance under 30 mL/min, ramipril is capped at 5 mg daily. In hepatic impairment start amlodipine at 2.5 mg daily. In East Africa choose once-daily, low-cost regimens and ask about herbal products.

Titration. Reassess after 4 weeks and increase to the maximum tolerated dose before adding another class.

Monitoring. Check creatinine and potassium 1 to 2 weeks after starting or increasing an ACE inhibitor, angiotensin receptor blocker, diuretic or mineralocorticoid receptor antagonist. Accept a creatinine rise of up to 30%. Check sodium after thiazide-like diuretics.

Adherence. Check home readings and pill counts before declaring treatment failure.

Stopping. Stop an ACE inhibitor permanently for angioedema, and for potassium over 6.0 mmol/L or a creatinine rise over 30% not explained by volume depletion. Switch an ACE inhibitor to an angiotensin receptor blocker for cough.

Common errors. Combining an ACE inhibitor with an angiotensin receptor blocker, starting a thiazide-like diuretic in gout, and adding a beta blocker as first-line without an indication.

Referral and escalation. Refer for pressure of 180/120 mmHg or over with organ damage, suspected secondary hypertension, hypertension under age 40, or pressure over target despite three drugs.

Hypertension Medicine Selection

Principles And Patient Context

Medicine Selection And Regimens

Dose Adjustment And Monitoring

Switching, Stopping And Escalation