What to prescribe (and to whom) are questions of on-going debate and investigation. The following are some generally accepted recommendations:
For most patients without complicating conditions
Diuretics are usually recommended as first-line treatment for patients without complications either alone or together with an ACE inhibitor, ARB, beta-blocker, or calcium channel blocker. Diuretics are generally safe, effective, and less expensive than other high blood pressure medications.
There are reasons why medications other than diuretics would be selected first. See the following descriptions.
For older adults
Diuretics continue to be the best choice for most older adults. The initial dose in people over 65 should generally be half the dose used in younger adults. Blood pressure should be checked both while seated and standing because older adults may drop their blood pressure while standing.
Because of a concern for drug interactions and side effects, some physicians are reluctant to give high blood pressure drugs to elderly patients. The scientific information, however, strongly supports the use of diuretics or beta blockers in the elderly (including those with isolated systolic hypertension) to lower the risk of heart attack, stroke, and heart failure.
For patients with diabetes
Studies suggest that people with diabetes may need medication if their blood pressure is 130/80 mm Hg or higher. This is to protect the heart and help prevent other complications common to both diseases. In general, ACE inhibitors and ARBs are the first choice for people with diabetes, since they also appear to protect the kidneys. In many cases, however, combinations are required to achieve blood pressure goals. In such cases, low-dose diuretics or calcium-channel blockers are added as needed.
For patients with isolated systolic hypertension
Isolated high systolic pressure is usually treated with a diuretic. A long-acting calcium-channel blocker may be an alternative, although some experts believe that ACE inhibitors or ARBs are proving to be the best choice in this group.
For patients with heart failure
People with heart failure generally should be given ACE inhibitors, often in combination with a beta-blocker and a diuretic.
For patients who have had a heart attack
ACE inhibitors and beta blockers are generally used following a heart attack.
For patients who are pregnant
Most women who develop high blood pressure only during pregnancy (gestational hypertension) are at low risk for preeclampsia and require no treatment, other than monitoring once the pregnancy is completed. Women who have high blood pressure and plan to or become pregnant should talk with your obstetrician about medications.
All blood pressure medications cross the placental barrier. ACE inhibitors, ARBs, and direct renin inhibitors have harmful effects to a fetus, including kidney disease and fatalities. They should be avoided during pregnancy. Beta-blockers should not be used during the early stages of pregnancy -- later use can be considered by your obstetrician. Labetalol is often used if a pregnant patient needs a beta blocker. Methyldopa has been the most researched blood pressure medication during pregnancy and may be selected by your doctor if you are diagnosed with high blood pressure while pregnant.
Steven Kang, MD, Division of Cardiac Pacing and Electrophysiology, East Bay Arrhythmia, Cardiovascular Consultants Medical Group, Oakland, CA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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