Managing Treatment-Resistant Patients with High Blood Pressure
Approximately 10% of hypertensive patients are “resistant,” meaning they require more than three drugs, including a diuretic, to control blood pressure. Many more patients on three or more drugs have uncontrolled BP due to inadequate treatment regimens or poor adherence.
Here are some suggested strategies to help patients reach BP goals:
- Investigate possible pseudoresistance due to white coat hypertension, poor adherence, or poor BP-measuring technique.
- Check for other contributing factors, including meds that can increase BP, such as NSAIDs, or high dietary sodium.
- Optimize medications with three core BP-lowering meds: a diuretic, an ACEI or ARB, and a calcium channel blocker.
- Try to use either chlorthalidone or indapamide as a diuretic as there is more evidence that these improve CV outcomes compared to hydrochlorothiazide. (For CrCl < 30 mL/min, use a loop diuretic such as furosemide.)
- Consider an aldosterone antagonist (such as spironolactone) if a fourth med is required, and monitor renal function and potassium.
- Save beta-blockers for a fifth medication option, unless patients require one anyway due to angina, heart failure, or post-MI.
- If patients consistently have high BP in the morning, advise them to take one or more meds at bedtime.
- Check for secondary hypertension causes such as sleep apnea and primary aldosteronism, especially if BP remains high while treating with multiple meds.
Need to know more?
The above post was created from recommendations on the topic published in our trusted newsletters. These recommendations also include Detail-Documents to help explain the rationale behind our recommendations and provide you with additional tools to help improve patient care; tools such as patient education handouts, drug comparison charts, FAQs, and more. Download our PL Chart: Treatment of Hypertension: JNC 8 and More, to view a sample. To view other Detail-Documents on this month’s topics, subscribe today.
Want to know more about other hot medication management topics?
This is just one topic of many. Every month we publish 10-12 recommendations and supporting Detail-Documents on the hottest topics in drug therapy and medication management. This month’s additional topics include:
- Med choices after coronary artery bypass graft (CABG) surgery.
- Ensuring that women who are pregnant or breastfeeding get enough iodine.
- New guidelines will encourage using weight loss drugs to control obesity and weight-related conditions.
- When and how to use statins in adults UNDER age 40 or OVER age 75.
- Whether folic acid reduces cardiovascular risk.
Go to the table of contents now for each Letter to see the full list:
Tell us what you’re doing:
Share with us below in the comments!
- Prescribers: Do you have a preferred combination of medications for treating resistant hypertension?
- Pharmacists: How do you help hypertensive patients adhere to their treatment regimen and stick with their medications?