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HT Update: Management of Hypertension Using Combination Therapy

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eMediNexus    22 February 2022

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The clinical data have shown that over 70% of adults with primary hypertension require a minimum of two antihypertensive agents, either starting initially as combination therapy or as add-on therapy if monotherapy and lifestyle modifications dont show adequate pressure level control.

Classes of antihypertensive medications most generally employed in combination therapy for the treatment of hypertension are - thiazide diuretics, calcium channel blockers (CCB), angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs).

The simultaneous use of ACEIs and ARBs is restricted. Studies have proved that black patients must receive a minimum of one agent as a thiazide diuretic or a calcium channel blocker.

Patients with heart failure with reduced ejection fraction should receive initial treatment with a beta-blocker and an ACEI or ARB (or an angiotensin receptor-neprilysin inhibitor), succeeded by the addition of a mineralocorticoid receptor antagonist and a diuretic assessed by volume status. Also in these patients, morbidity and mortality will be improved by prescribing beta-blockers like carvedilol, extended-release metoprolol, and bisoprolol. Patients with heart failure with reduced ejection fraction (HFrEF) should be administered one of any of these agents, unless contraindicated. Beta-blockers are commonly added once the patients symptoms of volume overload subside.

Hypertensive patients with chronic renal disorder and proteinuria should be treated with an ACEI or ARB plus a thiazide diuretic or a calcium channel blocker.

The patients with diabetes mellitus should receive treatment similar to patients without diabetes unless there is proteinuria, which changes the treatment approach to combination therapy with an ACEI or ARB.

Strategies for Initiating and Titrating Antihypertensive Drugs

The treatment should be started with one drug; if adequate control isnt achieved in one month, titration to maximal dosage before adding an extra agent should be done.

The treatment should be started with one drug; if adequate control isnt achieved in one month, the addition of an extra agent before titrating the initial drug to maximal dosage should be done.

Initiate the treatment with two drugs simultaneously; if adequate control isnt achieved in one month, titration to maximal dosages before adding an extra agent should be done, or a 3rd agent should be added.

Source: Smith DK, Lennon RP, Carlsgaard PB. Managing Hypertension Using Combination Therapy. Am Fam Physician. 2020 Mar 15;101(6):341-349. PMID: 32163253.

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