Hypertension: Drug Sequencing Management

Choosing drugs(i) for persons newly diagnosed with hypertension

Abbreviations + details:

  1. ACE inhibitor (e.g. perindopril, lisinopril or ramipril) or angiotensin receptor blockers (ARB) (e.g. losartan, candesartan)
  2. Dihydropyridine calcium-channel blocker (e.g. amlodipine). If not tolerated or if deemed at high risk of heart failure, ’D’ drugs can be used instead. Where a C drug is preferred but not tolerated, verapamil or diltiazem may be used (note: dose with caution with PIs as these may increase plasma concentrations of these calcium-channel blockers, potentially leading to toxic reactions)
  3. Thiazide-type diuretic. e.g. indapamide or chlorthalidone as a first choice. This excludes thiazides (e.g. hydrochlorothiazide (HCTZ), bendroflumethiazide etc.). However, if thiazide-type diuretics are not available low-dose thiazides may be used as a treatment alternative


Notes:

  1. Two antihypertensive drugs (ideally administered as single tablet combinations, where available) are increasingly recommended both as first-line therapy (A + C or A + D) and second-line therapy particularly if the initial pre-treatment SBP is ≥ 160 mmHg
  2. Black persons are those of African or Caribbean descent, and not mixed race, Asian or Chinese persons. Either A+C or C+D can be used for this
  3. Wait 4-6 weeks to assess whether target, see Prevention of CVD, is achieved; if not, go to next step
  4. Some calcium-channel blockers interact marginally with the pharmacokinetics of ARVs, see Drug-drug Interactions between Antihypertensives and ARVs
  5. Requirement of 4-5 drugs to manage hypertension needs specialist advice

* Use A+D if C not tolerated