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Figure 11 3 The British Hypertension Society s recommendations for combining blood pressure lowering drugs The ABCD rule A, Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker; B, -blocker (the parentheses indicate that -blockers should no longer be considered ideal first-line agents); C, calcium channel blockers; D, diuretic (thiazide) (Reprinted, with permission, from Williams B; British Hypertension Society Guidelines for management of hypertension: report of the Fourth Working Party of the British Hypertension Society, 2004BHS IV J Hum Hypertens 2004 Mar;18(3):139 185)
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allows faster blood pressure reduction without substantially higher intolerance rates and is likely to be better accepted by patients Improved blood pressure control can also be achieved by combining an ACE with an ARB When an initial agent is selected, the patient should be informed of common side effects and the need for diligent compliance Treatment should start at a low dose, and unless the initial blood pressure is very high (> 160/100 mm Hg), follow-up visits should usually be at 4- to 6-week intervals to allow for full medication effects to be established (especially with diuretics) before further titration or adjustment If, after titration to usual doses, the patient has shown a discernible but incomplete response and a good tolerance of the initial drug, a second medication should be added As a rule of thumb, a blood pressure reduction of 10 mm Hg can be expected for each antihypertensive agent added to the regimen Hypertension can be controlled in most patients with one-drug or two-drug regimens that combine complementary agents A small number of patients require three, four, or even more medications in combination Patients who are compliant with their medications and who do not respond to these combinations should usually be evaluated for secondary hypertension before proceeding to more complex regimens
Special Considerations in the Treatment of Diabetic Hypertensive Patients
Hypertensive patients with diabetes are at particularly high risk for cardiovascular events More aggressive treatment
Systemic Hypertension
of hypertension in these patients prevents progressive nephropathy, and a meta-analysis supports the notion that lower treatment goals are especially effective at reducing cardiovascular risk in diabetics compared with nondiabetics Because of their beneficial effects in diabetic nephropathy, ACE inhibitors (and ARBs in intolerant patients) should be part of the initial treatment regimen However, most diabetics require combinations of three to five agents to achieve target blood pressure, usually including a diuretic and a calcium channel blocker or -blocker In addition to rigorous blood pressure control, treatment of persons with diabetes should include aggressive treatment of other risk factors and early intervention for coronary disease and left ventricular dysfunction
CMDT 2008
environmental factors such as diet, activity, stress, or access to health care services In any case, as in all persons with hypertension, a multifaceted program of education and lifestyle modification is warranted Early introduction of combination therapy has been advocated Because it appears that ACE inhibitors and ARBs in the absence of concomitant diuretics are less effective in blacks than in whites, initial therapy should generally be a diuretic or a diuretic combination with a calcium channel blocker Some experts have recommended a goal blood pressure of 130/80 mm Hg for blacks at high risk for cardiovascular events as well as those with diabetes
Follow-Up of Patients Receiving Hypertension Therapy
Once blood pressure is controlled on a well-tolerated regimen, follow-up visits can be infrequent and laboratory testing limited to tests appropriate for the patient and the medications used Yearly monitoring of blood lipids is recommended, and an electrocardiogram should be repeated at 2- to 4-year intervals depending on whether initial abnormalities are present, the presence of coronary risk factors, and age Pharmacy care programs have been shown to improve compliance with medications Patients who have had excellent blood pressure control for several years, especially if they have lost weight and initiated favorable lifestyle modifications, should be considered for step-down of therapy to determine whether lower doses or discontinuation of medications are feasible
Azizi M et al Combined blockade of the renin-angiotensin system with angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor antagonists Circulation 2004 Jun 1;109(21):2492 9 [PMID: 15173039] Barzilay JI et al; ALLHAT Collaborative Research Group Cardiovascular outcomes using doxazosin vs chlorthalidone for the treatment of hypertension in older adults with and without glucose disorders: a report from the ALLHAT study J Clin Hypertens (Greenwich) 2004 Mar;6(3):116 25 [PMID: 15010644] Brewster LM et al Systematic review: antihypertensive drug therapy in black patients Ann Intern Med 2004 Oct 19;141 (8):614 27 [PMID: 15492341] Cohen JD Managing hypertension: state of the science J Clin Hypertens (Greenwich) 2006 Oct;8(10 Suppl 3):5 11 [PMID: 17028478] Cushman WC et al Achieving blood pressure goals: why aren t we J Clin Hypertens (Greenwich) 2006 Dec;8(12):865 72 [PMID: 17170612] Dahlof B et al; ASCOT Investigators Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial Lancet 2005 Sep 10 16;366 (9489):895 906 [PMID: 16154016] Iino Y et al; Japanese Losartan Therapy Intended for the Global Renal Protection in Hypertensive Patients (JLIGHT) Study Investigators: Renoprotective effect of losartan in comparison to amlodipine in patients with chronic kidney disease and hypertension Hypertens Res 2004 Jan;27(1):21 30 [PMID: 15055252] Julius S et al; VALUE trial group Outcomes in hypertensive patients at high cardiovascular risk treated with regimens based on valsartan or amlodipine: the VALUE randomised trial Lancet 2004 Jun 19;363(9426):2022 31 [PMID: 15207952]
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