Complete Guide to Blood Pressure Medications: Types, Effects, and Management

Between August 2021 and August 2023, 47.7% of adults in the US had high blood pressure. The condition becomes more common with age. Among adults aged 18–39, 23.4% were affected, compared to 52.5% of those aged 40–59, and 71.6% of individuals aged 60 and older.

High blood pressure can lead to serious issues like heart attacks, strokes, and kidney damage. It makes your heart work too hard and can weaken it over time.

However, blood pressure medicines can help keep your heart healthy and your blood pressure in a safe range. These medicines work in different ways to lower your blood pressure and protect your body.

🔑 Key Takeaways

Diuretics, or water pills, help your kidneys remove extra water and salt to lower blood pressure.

Beta blockers slow your heart rate and reduce blood pressure by blocking adrenaline.

ACE inhibitors relax your blood vessels by stopping the production of a substance that narrows them.

ARBs also relax your blood vessels by blocking the same substance, making it easier for blood to flow.

Calcium channel blockers open your blood vessels by stopping calcium from tightening them.

Alpha blockers lower blood pressure by relaxing blood vessel muscles and can help with prostate problems.

What Are Blood Pressure Medications?

Blood pressure is one of the most important measurements for keeping your heart healthy. Blood pressure medications are medicines that doctors give to help keep your blood pressure in a safe range. This makes sure your heart and blood vessels work well.

Blood pressure is the measurement used to gauge how hard blood pushes against the walls of your blood vessels as it flows through them. If this pressure is too high or too low, it can be dangerous.

Types of Blood Pressure Medications

Here are the major types of blood pressure medications and what you should know about them.

Diuretics (Water Pills)

Diuretics, often called water pills, help control high blood pressure. They help your kidneys remove extra water and salt from your body through urine. With less fluid in your blood vessels, your blood pressure drops.

Types of Diuretics

There are several types of diuretics: thiazide, loop, potassium-sparing, osmotic, and carbonic anhydrase inhibitors.

  1. Thiazide Diuretics

Thiazide diuretics are commonly prescribed for high blood pressure. They help your kidneys remove extra water and salt. However, they can also cause you to lose potassium, an important mineral for your body. Examples include:

In one study, it was highlighted that Diuretics helped the body remove extra water and salt. Thiazides, a type of diuretic, have been essential in treating hypertension for over 50 years. They effectively lower blood pressure and reduce the risk of heart problems. Hydrochlorothiazide is the most commonly used thiazide.

Doctors usually prescribe it in doses of 12.5 to 25 mg each day. When you combine it with potassium-sparing diuretics or with potassium tablets, you can lessen the risk of developing a low potassium level, or hypokalemia.

  1. Loop Diuretics

Loop diuretics are not usually the first choice for high blood pressure. They are more often used to remove excess fluid in conditions like heart failure, kidney problems, liver disease, and swelling.

These diuretics are stronger than thiazides, so you might need to pee a lot. They also cause potassium loss. Examples include:

  • Bumetanide (Bumex)
  • Ethacrynic acid (Edecrin)
  • Furosemide (Lasix)
  • Torsemide (Demadex)

Studies show that torsemide offers some advantages over furosemide. It lasts longer, has more consistent absorption, and usually requires only one dose per day. While loop diuretics are less effective at lowering blood pressure in high doses compared to thiazides, they tend to cause fewer side effects, such as low potassium levels (hypokalemia) and glucose intolerance.

  1. Potassium-Sparing Diuretics

These diuretics help you keep potassium while removing excess water and salt. They are usually used with other diuretics because they are less powerful on their own. Examples include:

  • Amiloride (Midamor)
  • Eplerenone (Inspra)
  • Spironolactone (Aldactone, Carospir)
  • Triamterene (Dyrenium)

According to a study, potassium-sparing diuretics provide moderate blood pressure reduction when used with other antihypertensive medications. However, they are not well-studied as standalone treatments. Higher doses might work better, but there’s not enough research to confirm this.

These medications are usually well-tolerated, but you should use them carefully to avoid high potassium levels (hyperkalemia), especially if you have kidney problems.

  1. Osmotic Diuretics

Osmotic diuretics are typically given intravenously (IV) and are not common with standard treatment for high blood pressure. They are generally reserved to help lower dangerously high pressure within the brain or eyes, or to treat low urine output from kidney failure. The main drug in this group is mannitol (Osmitol).

  1. Carbonic Anhydrase Inhibitors

These diuretics are mainly used to treat glaucoma, but they can also help with altitude sickness, epilepsy, and increased pressure around the brain. They work by reducing an enzyme in the kidneys, making your urine more alkaline. This helps lower pressure in the eyes for glaucoma treatment. Examples include:

  • Acetazolamide (Diamox)
  • Dichlorphenamide (Keveyis)
  • Methazolamide (Neptazane)

Side Effects

Water pills can have some side effects. Here are a few to watch out for:

  • Increased Urination
  • Dehydration
  • Tiredness or Weakness
  • Dizziness
  • Blood Chemistry Changes
  • Gout attacks

Risks of Water Pills

Diuretics can cause your kidneys to lose potassium, which is important for muscle and heart function. Low potassium levels, called hypokalemia, can lead to muscle weakness, cramps, and an irregular heartbeat.

Normal potassium levels are between 3.5 to 5.2 mEq/L. If your level drops below 3 mEq/L, you have severe hypokalemia. Symptoms include:

  • Constipation
  • Fatigue
  • Heart murmurs
  • Numbness and tingling

To treat low potassium, you might need potassium supplements or a different diuretic. Eating potassium-rich foods can help, but it might not be enough alone.

Also, too much fluid loss can cause low blood pressure, leading to dizziness, blurred vision, fainting, and fatigue. If you experience these symptoms, inform your doctor. They might adjust your diuretic or prescribe a medication to help with low blood pressure.

🩺 Doctor’s Note

Stopping diuretics usually causes your high blood pressure or heart problems to return. In elderly patients, stopping water pills can lead to heart failure symptoms or high blood pressure again. It’s important to stop taking them only under your doctor’s supervision, especially during the first month.

Beta Blockers

Beta-blockers are medicines that help lower your blood pressure. They are also known as beta-adrenergic blocking agents. These medicines block the hormone epinephrine, which you might know as adrenaline. When you take a beta blocker, it doesn’t allow adrenaline to enter cells, which ends up causing your heart to beat more slowly and with less force. This can help to lower your blood pressure.

Additionally, beta-blockers help relax your veins and arteries, making it easier for blood to flow through your body.

Beta-blockers aren’t usually the first choice for treating high blood pressure. They are often used when other medicines, like diuretics, haven’t worked well enough. Sometimes, a beta blocker is part of a combination of medicines to help lower your blood pressure. Beta-blockers also treat other conditions, such as:

  • Irregular heart rhythms, known as arrhythmias
  • Heart failure
  • Chest pain, called angina
  • Heart attacks
  • Migraines
  • Certain types of tremors
  • Anxiety

Types of Beta Blockers

There are different types of beta blockers. Some mainly affect your heart, while others work on your heart and blood vessels. The right one for you depends on your specific health needs. Here are some examples:

  • Acebutolol
  • Atenolol (Tenormin)
  • Bisoprolol
  • Metoprolol (Lopressor, Toprol XL)
  • Nadolol (Corgard)
  • Nebivolol (Bystolic)
  • Propranolol (Inderal LA, InnoPran XL)

Side Effects

Like all medicines, beta-blockers can have side effects. Here are some common ones to watch for:

  • Cold hands or feet
  • Feeling very tired
  • Gaining weight
  • Dizziness or feeling light-headed

Less common side effects include:

  • Feeling depressed
  • Shortness of breath
  • Trouble sleeping

Beta-blockers that affect both the heart and blood vessels are usually not recommended if you have asthma. They might trigger severe asthma attacks. If you have diabetes, beta-blockers can hide signs of low blood sugar, such as a rapid heartbeat. It’s important to check your blood sugar regularly if you’re taking a beta blocker and have diabetes.

Some beta-blockers can change your cholesterol and triglyceride levels. They might slightly raise triglycerides, a type of fat in your blood, and lower your good cholesterol, high-density lipoprotein (HDL) cholesterol. These changes are usually temporary.

⚠️ Important Considerations

Never stop taking a beta-blocker suddenly. Doing so can increase your risk of a heart attack or other heart problems. If you need to stop, talk to your doctor first. They can help you reduce your dose safely.

ACE Inhibitors

ACE inhibitors are medicines that help lower your blood pressure by relaxing your veins and arteries. They block the body’s process of making a substance called angiotensin II.

Angiotensin II narrows your blood vessels, which can raise your blood pressure and make your heart work harder.

By blocking this substance, ACE inhibitors allow your blood vessels to stay open, making it easier for blood to flow. This reduces the strain on your heart and helps protect your kidneys, especially if you have high blood pressure or diabetes.

ACE inhibitors aren’t just for high blood pressure. They help prevent, treat, or improve several conditions, including:

  • Coronary artery disease
  • Heart failure
  • Diabetes
  • Certain chronic kidney diseases
  • Heart attacks
  • Scleroderma (a disease that hardens the skin and connective tissues)
  • Migraines

Sometimes, doctors use ACE inhibitors along with other blood pressure medicines like diuretics or calcium channel blockers to get the best results. However, you should not take ACE inhibitors with certain other medications, such as angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, or direct renin inhibitors.

👍 Recommendation

The Joint National Committee on finding and treating high blood pressure has recently recommended that you start with ACE inhibitors, beta blockers, or diuretics to lower your blood pressure. ACE inhibitors are a great option for most people because they are safe, don’t negatively affect your body’s metabolism, and help your heart and kidneys.If an ACE inhibitor doesn’t work well enough for you, your doctor might add a diuretic or another medicine. This combination usually works well and is safe for 85% to 90% of patients. You can also use ACE inhibitors to treat congestive heart failure, which is when your heart doesn’t pump blood properly, and to prevent kidney problems from high blood pressure and diabetes.

Types of ACE Inhibitors

There are many ACE inhibitors available, and the best one for you depends on your health needs. For example, if you have chronic kidney disease, an ACE inhibitor might be especially beneficial. Common ACE inhibitors include:

  • Benazepril (Lotensin)
  • Captopril
  • Enalapril (Vasotec)
  • Fosinopril
  • Lisinopril (Zestril)
  • Moexipril
  • Perindopril
  • Quinapril
  • Ramipril (Altace)
  • Trandolapril

These medicines usually come in tablet form and are taken by mouth. Most people take them once a day, but your doctor will decide the best dose and schedule for you.

Side Effects

Like all medicines, ACE inhibitors can have side effects. Here are some to watch out for:

  • Dry cough
  • High potassium levels
  • Extreme tiredness or dizziness
  • Headaches
  • Loss of taste

Rarely, ACE inhibitors can cause:

  • Worsening kidney function
  • Swelling under the skin
🩺 Doctor’s Note

Be careful with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). They can make ACE inhibitors less effective and also cause swelling in the legs.

Angiotensin II Receptor Blockers (ARBs)

ARBs are medicines that lower your blood pressure by relaxing your veins and arteries. They are also called angiotensin II receptor blockers. These medicines stop a chemical in your body called angiotensin II from working.

Angiotensin II narrows your blood vessels, which can raise your blood pressure and make your heart work harder. By blocking angiotensin II, ARBs help your blood vessels stay open. This makes it easier for blood to flow and reduces your blood pressure.

In one study, ARBs were moderately effective in lowering blood pressure in people with hypertension. The average reduction in blood pressure at maximum recommended doses was about 8 mmHg for systolic blood pressure (SBP) and 5 mmHg for diastolic blood pressure (DBP).

Additional trials including more than 13,000 individuals have shown lower doses, such as one-eighth or one-fourth of the maximum dose, still achieve 60% to 70% of the maximum effect. A half-dose reaches about 80% of the maximum effect. Higher doses have not shown significant additional benefits. The trials reviewed lasted 3 to 12 weeks.

While ARBs are as effective as ACE inhibitors, the short duration of studies and limited data on side effects leave gaps in understanding their long-term safety.

ARBs are not just for high blood pressure. They also help with other health issues, such as:

  • Chronic kidney disease
  • Heart failure
  • Kidney failure due to diabetes

Using ARBs for these conditions can prevent serious health problems and improve your quality of life.

Types of ARBs

There are several ARBs available. The best one for you depends on your health and the condition you are treating. Common ARBs include:

  • Azilsartan (Edarbi)
  • Candesartan (Atacand)
  • Irbesartan (Avapro)
  • Losartan (Cozaar)
  • Olmesartan (Benicar)
  • Telmisartan (Micardis)
  • Valsartan (Diovan)

Side Effects

Like all medicines, ARBs can have side effects. Here are some to watch out for:

  • Dizziness
  • High potassium levels
  • Swelling of the skin

Some people taking olmesartan (Benicar) experience digestive problems. If you have severe diarrhea or lose a lot of weight while taking this medicine, talk to your healthcare team right away.

🩺 Doctor’s Note

Many people who develop a cough while on an ACE Inhibitor will be switched to an ARB. Although ARBs and ACE Inhibitors address angiotensin II, the mechanisms are different. As such, those who cannot tolerate ACE Inhibitors due to cough are generally able to tolerate ARBs.  

Calcium Channel Blockers

Calcium channel blockers (CCBs) are medicines that help lower your blood pressure. They do this by stopping calcium from entering the cells of your heart and arteries. Calcium makes your heart and arteries squeeze tighter. When calcium channel blockers block this, your blood vessels relax and open up. This makes it easier for blood to flow through them.

Studies show that CCBs can lower systolic pressure by 12-15 mmHg and diastolic pressure by 8-10 mmHg. The exact effect depends on the drug and dose. If you have mild hypertension, they work well on their own. For more resistant cases, they’re combined with drugs like ACE inhibitors or ARBs.

CCBs are versatile medicines used to treat several heart and circulatory conditions, including:

  • High blood pressure
  • Chest pain
  • Irregular heartbeats
  • Coronary artery disease

For some people, calcium channel blockers work better than other blood pressure medicines like beta blockers, ACE inhibitors, or ARBs. This makes them a valuable option in your treatment plan.

Types of Calcium Channel Blockers

There are two main types of calcium channel blockers, each working a bit differently.

Dihydropyridines mainly affect your arteries. They help to relax and widen your blood vessels, which lowers your blood pressure. Common dihydropyridines include:

  • Amlodipine (Norvasc)
  • Felodipine (Plendil)
  • Nifedipine (Procardia)
  • Nicardipine (Cardene)
  • Isradipine

Non-dihydropyridines work on both your heart muscle and blood vessels. These can help slow your heart rate and reduce the force of your heart’s contractions. Examples are:

  • Diltiazem (Cardizem, Tiazac)
  • Verapamil (Verelan, Calan)

Dihydropyridine calcium antagonists are more commonly used to treat high blood pressure because they effectively reduce arterial pressure and vascular resistance.

Side Effects

Like all medicines, calcium channel blockers can have side effects. Here are some to be aware of:

  • Constipation
  • Dizziness
  • Fast heartbeat you can feel
  • Extreme tiredness
  • Flushing
  • Headache
  • Nausea
  • Swelling in the feet and lower legs

Additionally, avoid grapefruit products while taking diltiazem and verapamil. Grapefruit juice can interact with these medicines and affect your heart rate and blood pressure.

⚠️ Important Consideration

Avoid grapefruit products, especially if you’re using diltiazem or verapamil. These can lead to harmful interactions.

Research has shown this interaction has been known since 1989 and is caused by components in grapefruit juice that block an enzyme called CYP3A4 in your intestines. When this enzyme is blocked, your body breaks down the medication more slowly, increasing the amount of the drug in your system.As a result, this interaction can make the drug more effective than intended, which could lead to side effects such as low blood pressure or dizziness.

Alpha Blockers for High Blood Pressure

Alpha blockers are medicines that help lower your blood pressure by preventing a hormone called norepinephrine from tightening the muscles in the walls of your smaller arteries and veins. When these muscles stay relaxed, your blood vessels remain open, allowing blood to flow more easily. This relaxation improves blood flow and lowers your blood pressure.

Additionally, alpha blockers relax other muscles in your body, which is why they are sometimes used to help older men with prostate problems improve urine flow.

Alpha blockers are typically not the first choice for treating high blood pressure. Instead, they are used alongside other medicines, like diuretics, when blood pressure is hard to control. Additionally, alpha blockers are prescribed to treat an enlarged prostate, a condition also known as benign prostatic hyperplasia (BPH). Using alpha blockers for BPH can help improve urine flow and reduce symptoms.

Studies show that these medications can lower blood pressure by about 11.7/6.9 mmHg when taken at the right dose. They’re particularly helpful for older men because they also ease urinary problems caused by an enlarged prostate.

In cases of resistant hypertension, alpha blockers like doxazosin are often added to other medications. This can lower systolic blood pressure by an extra 4 mmHg.

To manage these, doctors may recommend taking the medication at bedtime or pairing it with diuretics. Despite these challenges, alpha-1 blockers remain a useful option for treating high blood pressure and prostate issues.

Types of Alpha Blockers

There are two main types of alpha blockers: short-acting and long-acting.

  1. Short-Acting Alpha Blockers work quickly but their effects only last for a few hours. Examples include Prazosin (Minipress)
  1. Long-Acting Alpha Blockers take longer to start working, but their effects last throughout the day. Examples are Doxazosin (Cardura) and Terazosin

Alpha blockers are also known by other names such as alpha-adrenergic blocking agents, alpha-adrenergic antagonists, and alpha-1 blockers.

Side Effects

When you start taking an alpha blocker, you might experience low blood pressure and dizziness. This can sometimes make you feel faint when you stand up quickly from sitting or lying down. To reduce this risk, doctors often recommend taking the first dose at bedtime.

Other possible side effects include:

  • Dizziness
  • Headache
  • Fast or pounding heartbeat
  • Weakness
  • Improved cholesterol levels
  • Risk of heart failure

Medication Management in Hypertension

Let’s break down the essential aspects of medication management for hypertension.

Pharmacologic Therapy Initiation

Depending on how high your blood pressure is and your overall health, your doctor will decide whether to start with one medicine or a combination of medicines.

Monotherapy

In stage 1 hypertension, where the systolic pressure is between 130-139 mm Hg or diastolic pressure is between 80-89 mm Hg, doctors often start treatment with one medicine. In fact, monotherapy is the most common approach when introducing blood pressure medications to an individual. By limiting medications to a single medication, side effects and potential for allergic reactions can be limited.

Some at-risk patients for side effects include those on a very low-salt diet, underweight or frail individuals, or those who have a history of multiple drug allergies. These individuals may be more prone to complications like orthostatic hypotension, electrolyte imbalance, or dizziness.

Additionally, patients with a history of multiple drug allergies or intolerances should be carefully treated, and monotherapy used until it becomes ineffective. Limiting treatment to a single medication may help prevent triggering reactions or side effects.

Combination Therapy

For stage 2 hypertension (systolic pressure of 140 mm Hg or higher or diastolic pressure of 90 mm Hg or higher), doctors will still usually start with one medication, but may ultimately require multiple medicines to lower blood pressure to an ideal level. These medicines work in different ways to lower blood pressure more effectively.

Combining medicines increases the chances of reaching your blood pressure goals more quickly. Common combinations include:

  1. ACE Inhibitor (or ARB) and a Calcium Channel Blocker

This combination uses the strengths of both calcium channel blockers and ACE inhibitors or ARBs. Calcium channel blockers help relax and widen your blood vessels, while ACE inhibitors or ARBs stop a hormone called angiotensin II from narrowing your blood vessels.

This combination offers superior protection for your heart compared to other medicine combinations. Also, it effectively lowers both the top number (systolic) and the bottom number (diastolic) of your blood pressure.

These medicines are usually well-tolerated and have fewer metabolic side effects compared to other combinations.

The ACCOMPLISH trial showed that combining an ACE inhibitor (benazepril) with a calcium channel blocker (amlodipine) was more effective in reducing heart-related events than combining an ACE inhibitor with a thiazide diuretic.

  1. ACE Inhibitor (or ARB) and a Thiazide Diuretic

This combination pairs thiazide diuretics, which help your body get rid of extra water and salt, with ACE inhibitors or ARBs, which relax your blood vessels. Together, they work to lower your blood pressure more effectively.

This combination is great for patients who have too much fluid in their bodies, like those with swelling (edema). Also, it’s especially useful for conditions like edema, osteoporosis (because thiazides help retain calcium), and kidney stones caused by high calcium levels in the urine.

Thiazide-like diuretics such as chlorthalidone and indapamide may have more effect than thiazide-type diuretics like hydrochlorothiazide. They are more powerful and last longer in your body, potentially providing better blood pressure control. That said, hydrochlorothiazide is frequently prescribed and may even be combined in a single pill with an ACE inhibitor.

Note that this combination might have a higher chance of causing some side effects, such as:

  • Low potassium levels (Hypokalemia)
  • High uric acid levels (Hyperuricemia)
  • Glucose intolerance

Specific Patient Populations

Managing high blood pressure effectively often requires special considerations based on an individual’s current health conditions.

  1. Diabetes

Most people with diabetes also have high blood pressure. In type 1 diabetes, kidney problems may lead to development of high blood pressure, while in type 2 diabetes, high blood pressure is often one of several related health issues requiring attention.

Using ACE inhibitors can help prevent kidney disease from getting worse, especially in patients with severely increased albuminuria (a high level of protein in the urine). Hypertension remains one of the most common causes of congestive heart failure (CHF) in people with diabetes, making proper management critical.

  1. Chronic Kidney Disease (CKD)

For adults with both high blood pressure and chronic kidney disease (CKD), the goal is to keep blood pressure below 130/80 mm Hg. Most people with CKD will need combination therapy to reach this target.

Proper management helps protect your kidneys from further damage. When managing CKD with albuminuria, treatment with a maximally tolerated dose of an ACE inhibitor or ARB is recommended for its protective benefits.

  1. Pregnancy

Women with high blood pressure who become pregnant should avoid ACE inhibitors, ARBs, and direct renin inhibitors because these medicines can harm a developing baby. It’s essential to talk to your doctor about safe alternatives if you are pregnant or planning to become pregnant.

Commonly used options during pregnancy include labetalol, nifedipine, hydrochlorothiazide, or methyldopa.

  1. Heart Failure

Certain calcium channel blockers (nondihydropyridine) are not recommended for adults with heart failure and high blood pressure. Instead, guideline-directed management and therapy (GDMT) should be used to keep blood pressure below 130/80 mm Hg.

This approach includes medicines like:

  • ACE inhibitors
  • ARBs
  • ARB-neprilysin inhibitors
  • Beta blockers
  • Diuretics
  • Sodium-glucose cotransporter 2 (SGLT-2) inhibitors
  • Mineralocorticoid receptor antagonists
  1. Hypertension in Black Adults

For most Black adults with high blood pressure, using two or more medicines is recommended to achieve a blood pressure target of less than 130/80 mm Hg.

The historic focus on single-drug blood pressure responses in Black individuals should be de-emphasized in favor of treating this high-cardiovascular-risk group intensively with initial combination therapy.

  1. Post-Stroke or Transient Ischemic Attack (TIA)

For adults who have had an acute ischemic stroke and have high blood pressure, it’s important to lower blood pressure below 185/110 mm Hg before starting thrombolytic therapy (a treatment to dissolve blood clots).

In patients treated with intravenous (IV) tissue plasminogen activator (tPA), blood pressure should also be maintained below 180/105 mm Hg for at least the first 24 hours after initiating drug therapy. Long-term management to help prevent stroke recurrence will involve treatment to lower blood pressure below 130/80 mm Hg.  

Monitoring and Adjustment

Here are the key aspects of monitoring and adjusting your hypertension therapy:

  1. Regular Follow-Up Appointments

After starting blood pressure medicines, you should see your doctor every two to four weeks until your blood pressure reaches the target level. Waiting four weeks to reevaluate after starting or intensifying therapy is typically appropriate, allowing long-acting antihypertensive drugs enough time to show their full blood pressure-lowering effect. Keeping a blood pressure log outside of your clinic visits is helpful to share with your provider.

  1. Dose Titration

If your blood pressure isn’t controlled, your doctor might increase the dose of your current medicine before adding another one.

Typically, doses of individual antihypertensive drugs are escalated to at least half the maximum recommended dose (to a moderate or high dose) before introducing additional therapy.

  1. Monitoring Kidney Function

After starting or adjusting certain blood pressure medicines, such as ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, and diuretics, your doctor will check your electrolytes and serum creatinine levels within one to three weeks. 

For patients on stable doses of medications, electrolytes and creatinine are typically monitored annually. These checks ensure your kidneys are functioning well and that the medicines are safe for you.

  1. Addressing Nonadherence

Not taking your medicines as prescribed can keep your blood pressure high. Nonadherence to medication is a common reason why an individual’s blood pressure remains uncontrolled despite being prescribed antihypertensive therapy.

In one meta-analysis, 45% of all patients with hypertension were partially or completely nonadherent to their medication regimen. If adherence is an issue, talk to your doctor for support and solutions.

Strategies like prescribing single-pill combinations rather than free equivalents or synchronizing prescriptions to minimize pharmacy trips can improve adherence. Staying consistent is key to controlling your blood pressure.

  1. Measuring Blood Pressure Accurately

Accurate blood pressure measurements are essential for making the right treatment decisions. Tools like ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) can help confirm your blood pressure levels and avoid misdiagnosis.

In one study, researchers reviewed data from 683 patients referred for ABPM at a Sydney teaching hospital. Each patient underwent same-arm blood pressure measurements using both devices before starting 24-hour monitoring.

The results showed that ABPM devices slightly underestimated blood pressure compared to mercury readings. On average, the difference was 1-3 mmHg for systolic and diastolic pressures. Factors like age, weight, gender, and the severity of hypertension were linked to small differences in device accuracy. However, these differences were minor and unlikely to affect clinical decisions.

ABPM devices are accurate enough for routine use. Although some factors can influence readings, the variations are too small to have a significant impact on patient care.

Medicines to Avoid Together

Certain combinations of blood pressure medications can lead to serious health issues and should be avoided to ensure your treatment remains safe and effective.

  1. ACE Inhibitors, ARBs, and Renin Inhibitors

Patients should not be prescribed both an ACE inhibitor and an ARB simultaneously, as combining these drugs is associated with adverse cardiovascular and kidney events.

Similarly, a direct renin inhibitor should not be combined with an ACE inhibitor or ARB. These combinations can overstimulate the renin-angiotensin system, leading to detrimental effects on heart and kidney function.

  1. Beta Blockers and Nondihydropyridine Calcium Channel Blockers

A beta blocker should not be simultaneously prescribed with a nondihydropyridine calcium channel blocker, such as diltiazem or verapamil. Both classes of drugs have negative inotropic (force of heart’s contraction) and chronotropic (heart rate) effects, which can collectively impair heart function.

This combination can lead to a decreased heart rate and weakened heart contractions, posing significant risks, especially in patients with underlying heart conditions.

  1. Alpha Blockers and Central Adrenergic Inhibitors

The combination of an alpha blocker, like prazosin, and a central adrenergic inhibitor, such as clonidine, should be avoided. Using these medications together can cause significant orthostatic hypotension, which is a sudden drop in blood pressure when standing up.

Orthostatic hypotension can lead to dizziness or fainting, increasing the risk of falls and related injuries.

Resistant Hypertension

Resistant hypertension occurs when your blood pressure remains high despite taking three antihypertensive medications at intermediate or high doses, including a diuretic. If you are prescribed four or more medications, whether your blood pressure is controlled or not, you are considered to have treatment-resistant hypertension.

Refractory hypertension is an even more severe form, defined by uncontrolled blood pressure despite taking five or more antihypertensive drugs. Recognizing resistant hypertension is crucial because it increases the risk of serious health issues like heart disease and stroke.

Managing resistant hypertension involves several important steps to ensure your blood pressure is brought under control effectively:

  1. Evaluate for Secondary Causes

First, it’s essential to determine if there are any underlying conditions contributing to your high blood pressure. Secondary causes can include:

  • Renal artery stenosis. Narrowing of the arteries that supply blood to your kidneys.
  • Primary aldosteronism. Overproduction of the hormone aldosterone, which can increase blood pressure.
  • Pheochromocytoma. A rare tumor of the adrenal glands that can cause excessive production of hormones leading to high blood pressure.
  • Hyperthyroidism. Thyroid overactivity can lead to persistent elevated blood pressure.
  1. Confirm Medication Adherence and Accurate Blood Pressure Measurement

Ensure that you are taking your medications exactly as prescribed. Missing doses or not following the treatment plan can keep your blood pressure high. Additionally, accurate measurement of blood pressure is vital.

Incorrect measurements can lead to inappropriate treatment decisions. Make sure to follow proper techniques when measuring your blood pressure at home or during doctor visits.

  1. Advanced Treatments

If standard treatments do not work, your doctor may consider advanced options like renal denervation. This procedure targets the nerves in the kidneys to help lower blood pressure.

Early clinical trials, such as SYMPLICITY HTN-1 and HTN-2, showed that renal denervation (RDN) could lower blood pressure. But the more carefully controlled SYMPLICITY HTN-3 trial, which included fake procedures and better monitoring, did not find significant effects. Later studies, like SPYRAL HTN-OFF MED and RADIANCE-HTN SOLO, brought new hope. They showed moderate but meaningful reductions in blood pressure by using improved methods and strict guidelines.

RDN seems to work best for people with resistant hypertension and high nerve activity. Still, there are challenges. Results are not always consistent, techniques vary, and nerves may reactivate over time. Researchers are now studying its long-term benefits, the best ways to perform the procedure, and which patients will benefit most. If these questions are answered, RDN could become a good option for lowering blood pressure and reducing the need for daily medications.

  1. Addressing Nonadherence and White Coat Effect

Nonadherence to medication is a common reason why blood pressure remains uncontrolled. If you find it hard to stick to your medication schedule, discuss it with your doctor. Strategies such as using single-pill combinations or synchronizing prescription refills can help improve adherence.

The white coat effect, where blood pressure readings are higher in a clinical setting than they are in everyday life, should also be ruled out. While it might seem harmless, studies show it increases the risk of heart disease, including heart attacks and strokes, by 36%. People with white-coat hypertension are also twice as likely to die from heart disease compared to those with normal blood pressure.

However, if you’re already on blood pressure medication and your blood pressure only rises at the doctor’s office, this does not seem to increase your heart disease risk.

Final Words

You have many medicines to choose from, like diuretics that help remove extra water, beta blockers that slow your heart rate, and ACE inhibitors that relax your blood vessels. Each type works in a different way to lower your blood pressure and protect your heart.

It’s important to take your medicines as your doctor says and attend regular check-ups. Watch for any side effects and talk to your doctor if you have concerns.

Frequently Asked Questions

Can I stop taking my medication if I feel fine?

No. High blood pressure often has no symptoms but can still cause damage if untreated.

Can I take blood pressure medication during pregnancy?

Some are safe, but others, like ACE inhibitors or ARBs, can harm the baby. Always consult your doctor if you’re pregnant or planning to become pregnant.

Do over-the-counter supplements help lower blood pressure?

No. Supplements are not substitutes for prescribed medications and may interact with them.

What happens if I miss a dose?

Take it as soon as you remember, but skip it if it’s almost time for your next dose.

What should I avoid while taking blood pressure medications?

Avoid high-sodium foods, excessive alcohol, and certain over-the-counter drugs like decongestants.

Can blood pressure medications affect my kidneys?

Some medications, like ACE inhibitors or ARBs, may affect kidney function. Your doctor will monitor your kidney health with regular tests.

Sources

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  • Heran, B. S., Chen, J. M. H., Wang, J. J., & Wright, J. M. (2012). Blood pressure lowering efficacy of potassium-sparing diuretics (that block the epithelial sodium channel) for primary hypertension. Cochrane Database of Systematic Reviews, 2012(11), CD008167. https://doi.org/10.1002/14651858.CD008167.pub3
  • Amadio, P., Jr., Amadio, P. B., & Cummings, D. M. (1990). ACE inhibitors: A safe option for hypertension and congestive heart failure. Postgraduate Medicine, 87(1), 223–226, 231–232, 235–243. https://doi.org/10.1080/00325481.1990.11704535
  • Heran, B. S., Wong, M. M. Y., Heran, I. K., & Wright, J. M. (2008). Blood pressure lowering efficacy of angiotensin receptor blockers for primary hypertension. Cochrane Database of Systematic Reviews, 2008(4), CD003822. https://doi.org/10.1002/14651858.CD003822.pub2
  • Jones, K. E., Hayden, S. L., Meyer, H. R., Sandoz, J. L., Arata, W. H., Dufrene, K., Ballaera, C., Lopez Torres, Y., Griffin, P., Kaye, A. M., Shekoohi, S., & Kaye, A. D. (2024). The evolving role of calcium channel blockers in hypertension management: Pharmacological and clinical considerations. Current Issues in Molecular Biology, 46(7), 6315–6327. https://doi.org/10.3390/cimb46070377
  • Li, H., Xu, T.-Y., Li, Y., Chia, Y.-C., Buranakitjaroen, P., Cheng, H.-M., Huynh, M. V., Sogunuru, G. P., Tay, J. C., Wang, T.-D., Kario, K., & Wang, J.-G. (2022). Role of α1-blockers in the current management of hypertension. The Journal of Clinical Hypertension, 24(9), 1180–1186. https://doi.org/10.1111/jch.14556
  • Abegaz, T. M., Shehab, A., Gebreyohannes, E. A., Bhagavathula, A. S., & Elnour, A. A. (2017). Nonadherence to antihypertensive drugs: A systematic review and meta-analysis. Medicine (Baltimore), 96(4), e5641. https://doi.org/10.1097/MD.0000000000005641