drug therapy for high blood pressure

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CHAPTER I

INTRODUCTION

A. Background

High blood pressure, also called hypertension, is elevated pressure of the

blood in the arteries. Hypertension results from two major factors, which can be

present independently or together:1. The heart pumps blood with excessive force.

2. The bodys smaller blood vessels !"nown as the arterioles# narrow, so that

blood flow exerts more pressure against the vessels walls.

$lthough the body can tolerate increased blood pressure for months and even

years, eventually the heart may enlarge !a condition called hypertrophy#, which is

a major factor in heart failure. %uch pressure can also injure blood vessels in the

heart, "idneys, the brain, and the eyes.Two numbers are used to describe blood pressure: the systolic pressure !the

higher and first number# and the diastolic pressure !the lower and second

number#. Health dangers from blood pressure may vary among different age

groups and depending on whether systolic or diastolic pressure !or both# is

elevated. $ third measurement, pulse pressure, may also be important as an

indicator of severity.

CHAPTER II

DISCUSSION

A. Threatment of high !ood "re##ure $h%"erten#ion&

'. (ife#t%!e )odification#

a. *eight Reduction and )aintenance

1



Hypertension is closely correlated with excess body weight (National

High Blood Pressure Education Program Working Group, 199!.

$pproximately &'( of hypertensive patients are overweight ("omero,

#$$%!. )n the *ramingham study, +'( to '( of hypertension could be

attributed to being overweight or obese (&annel, 199!.

-esearch studies have documented the positive effects of weight

reduction as a strategy for blood pressure control ('rials o Hypertension

Pre)ention *olla+orati)e "esearch Group, 'he, 199#!. )n adults with

hypertension, metaanalysis shows that weight loss through diet or use of

orlistat is related to a modest reduction of blood pressure by up to +

mmHg systolic and / mmHg diastolic0 however, use of sibutramine

increased blood pressure despite weight loss (Hor)ath, #$$!. henever

indicated, weight reduction should be recommended. ven an initial loss

of as little as 1' pounds can have a beneficial effect on blood pressure.

eight loss can also improve the efficacy of antihypertensive medications

and the cardiovascular ris" profile.

)nitial weight loss and longterm weight control are both enhanced by

a regular exercise program. 3atient education and4or nutritional

counseling should be provided.

(-oore, #$$/ *ho+anian, #$$/ 0legal, #$$#/ ppel, 199%!

. Dietar% Inter+ention#

5se of a 6$%H !6ietary $pproaches to %top Hypertension# eating

plan has been shown in cohort studies to reduce incidence of congestive

2



heart failure by 2&( and incidence of stro"e by 1( in women (0ung,

#$$!. )n overweight or obese adults with elevated blood pressure,

compared to the 6$%H diet alone, the combination of the 6$%H diet

with exercise and weight loss resulted in greater declines in blood

pressure and left ventricular mass (Blumenthal, #$1$!.

$ relationship between dietary sodium inta"e and blood pressure has

been demonstrated in multiple clinical and epidemiological studies (2a3,

#$$$!. 7odest sodium restriction may also reduce the amount of

antihypertensive medications re8uired (ppel, #$$1!. However,

individuals vary in response to a reduced sodium inta"e. $mong

hypertensives, $frican $mericans, older patients and patients with renal

disease seem to be more sodium sensitive (4acks, #$$1!.

(Whelton, 199/ Neaton, 199!

c. )oderation of A!coho! Intake

$lcohol consumption has complex effects on the cardiovascular

system. $lcohol consumption raises both systolic and diastolic pressures,

but its effects appear to be greater on systolic pressure. %ignificant

elevations in blood pressure have been shown in individuals who

consumed an average of at least three standard drin"s per day compared

with nondrin"ers. $lcoholism may cause hypertension, and an alcoholic

is less li"ely to respond to any hypertension treatment recommendations

(0riedman, 199$!. %ome persons may develop transitory hypertension

during the first days of detoxification. $lcohol is a concentrated calorie

3



source that does not provide any nutrients, so reducing alcohol inta"e can

hasten weight reduction and may decrease triglyceride levels. $lthough

cohort studies suggest that modest alcohol consumption may reduce the

rate of myocardial ischemic events, alcohol use of up to 2 ounces per day

neither increases nor decreases total mortality or cardiovascular mortality

in those with hypertension (Beulens, #$$%!. The recommendation is to not

exceed a daily alcohol inta"e of one ounce of ethanol. 9ne ounce !/' m#

of ethanol is e8uivalent to two drin"s per day. )t is recommended that men

have no more than one ounce of ethanol per day !two drin"s# and women

have no more than '.& ounce of ethanol per day !one drin"#. 9ne drin" is

12 ounces of beer, & ounces of wine or 1.& ounces of ;' proof li8uor.

(-ahes3aran, 1991!.

d. Ade,uate Ph%#ica! Acti+it%

pidemiological studies suggest that regular aerobic physical activity

may be beneficial for both prevention and treatment of hypertension, to

enable weight loss, for functional health status, and to diminish allcause

mortality and ris" of cardiovascular disease. Thirty to fortyfive minutes

of bris" wal"ing or other activity most days of the wee" at target heart

rate !<22'age= x &( > target heart rate# is ade8uate, inexpensive and

effective (Pate, 199!. However, regular physical activity of even lower

intensity and duration has been shown to be associated with about a 2'(

decrease in mortality in cohort studies (2eit5mann, #$$%!. 9ther aerobic

activities !bi"ing, swimming, jogging, etc.# may be more enjoyable.

4



-esistive isotonic activities, when done as the only form of exercise

training, are not recommended to lower blood pressure in hypertensive

patients. (World Hypertension 2eague, 1991!

e. Pota##ium

High dietary potassium inta"e is associated with lower blood pressure.

hile data from individual trials have been inconsistent, metaanalyses

have documented a bloodpressurelowering effect (ppel, #$$9!. There is

no direct evidence that potassium supplementation lowers blood pressure

chronically (Whelton, 199%/ 0other+y, 199#/ *appuccio, 1991!.

f. Toacco A+oidance

-ecent data using ambulatory blood pressure monitoring suggests that

nicotine may indeed increase blood pressure and could account for some

degree of blood pressure lability (Bolinder, 199!. )n addition, it is a

major ris" factor for atherosclerotic cardiovascular disease. $t each visit,

establish tobacco use status.

g. Re!a-ation and Stre## )anagement

$lthough studies have not demonstrated a significant longterm effect

of relaxation methods on blood pressure reduction, relaxation therapy

may enhance an individuals 8uality of life and may have independent

effects on lowering coronary heart disease ris" (Eisen+erg, 199/

6ohnston, 1991!.

Ta!e '. (ife#t%!e )odification# to Pre+ent and )anage H%"erten#ion

5



)odification Recommendation A""ro-imate

S%#to!ic B!ood

Pre##ure Reduction

$Range& ?

eight reduction 7aintain normal body weight !body

mass index 1;.&[email protected] "g4m2#.

&2' mmHg41' "g

$dopt 6$%HBB

eating plan

Consume a diet rich in fruits, vegetables

and lowfat dairy products, with a

reduced content of saturated and total

fat.

;1@ mmHg

6ietary sodium

reduction

-educe dietary sodium inta"e to no

more than 1'' mmol per day !2.@ gsodium or + g sodium chloride#.

2; mmHg

3hysical activity ngage in regular aerobic physical

activity such as bris" wal"ing !at least

/'@& minutes per day, most days of the

wee"#.

@A mmHg

7oderation of

alcohol

consumption

imit consumption to no more than two

drin"s !e.g., 2@ oD. beer, 1' oD. wine, or

/ oD. ;' proof whis"ey# per day in most

men and to no more than one drin" per

day in women and lighterweight persons.

2@ mmHg

)ncrease dietary

potassium

inta"e

)ncrease dietary potassium inta"e to @.

gm per day !this is the amount provided

in the 6$%H diet#

2@ mm Hg

B *or overall cardiovascular ris" reduction, stop smo"ing.

BB 6$%H indicates 6ietary $pproaches to %top Hypertension.

? The effects of implementing these modifications are dose and time

dependent and could be greater for some individuals.

Ta"en from the %eventh -eport of the Eoint Fational Committee on

3revention, 6etection, valuation, and Treatment of High Glood 3ressure.

Hypertension 2''/0@2:12'+&2.

$ppel E. $%H 3osition paper: dietary approaches to lower blood pressure. 6

*lin Hypertens 2''A011:/&;+;.

6



/. Drug thera"%

$ thiaDidetype diuretic should be considered as initial therapy in most

patients with uncomplicated hypertension (Wright, #$1$/ ppel, #$$#!.

Gecause thiaDidetype diuretics have been shown to be as good or superior to

other drug classes in preventing cardiovascular disease morbidity and

mortality, they should be considered preferred initial therapy in most patients

(*ho+anian, #$$ !. However, studies support the use of specific alternative

drugs as initial therapy in the presence of specific coexisting diseases.

6iuretics have been shown to be as good or superior to other classes of drug

therapy in preventing cardiovascular disease morbidity and mortality, and

they are inexpensive (Psaty, #$$/ 22H' 7icers, *oordinators or the

22H' *olla+orati)e "esearch Group, 'he, #$$#!. ThiaDidetype diuretics

are especially useful for patients age && years or older with hypertension and

additional ris" factors for cardiovascular disease including the metabolic

syndrome and for patients age +' years or older with isolated systolic

hypertension (Wright, #$$/ 22H' 7icers, *oordinators or the 22H'

*olla+orati)e "esearch Group, 'he, #$$ !. The ris" of diabetes mellitus is

higher with diuretic and betabloc"ers than other firstline choices, and this

may be a consideration for patients at higher ris" for this disorder (Elliott,

#$$%!. $ntihypertensive and ipid owering Treatment to 3revent Heart

$ttac" Trial !$H$T#.

%tudies have demonstrated the cost effectiveness in older patients of

selecting drugs using evidencebased guidelines (0ischer, #$$8!. )n patients

7



for whom diuretics are contraindicated or poorly tolerated, use of an $C

inhibitor, angiotensin receptor bloc"er, betabloc"er or calcium antagonist is

appropriate. 9ther considerations when selecting initial drug therapy include

age, race, cost, drug interactions, side effects and 8uality of life issues. %ee

$ppendix G, Therapies, and $ppendix $, 6ose of $ntihypertensive

6rugs. )n general, diuretics and calcium channel bloc"ers appear to be more

effective as an initial treatment of hypertension in $frican $mericans. The

lowest recommended dose of the chosen drug should be used initially. )f

tolerated, the dose can be increased or additional medications added to

achieve goal blood pressure.

9ther classes of drugs should be reserved for special situations or as

additive therapy. %ee $ppendix G, Therapies. Coexisting medical

conditions may also justify the use of one of these classes of drugs. $n is the

use of an $C inhibitor in a patient with heart failure or diabetic

nephropathy. 3lease see )C%)s 6iagnosis and 7anagement of Type 2

6iabetes 7ellitus in $dults guideline for further information. $C inhibitors

and angiotensin receptor bloc"ers have been shown to be beneficial for

patients with renal disease !both diabetic and nondiabetic# by reducing

proteinuria and slowing the rate of decline in renal function (6aar, #$$/

godoa, #$$1/ Brenner, #$$1/ 6aar, #$$1!. $C inhibitors have also been

shown to provide symptomatic relief and prolong life for patients with heart

failure and are the initial drug of choice for this condition. $C inhibitors and

angiotensinreceptor bloc"ers have similar bloodpressurelowering effects,

8



but angiotensinreceptor bloc"ers are less often associated with the side effect

of cough (-atchar, #$$!. )nitial monotherapy with one of these agents is

appropriate in these patient populations. $ diuretic should be added if blood

pressure response is not satisfactory. vidence from a recent large trial

suggests that $C inhibitors may be less effective in $frican $mericans than

thiaDidetype diuretics in controlling blood pressure and in preventing stro"e

and cardiovascular disease (ppel, #$$#!.

Gased on metaanalyses of previous studies, betabloc"ers may be less

efficacious than other firstline alternatives in patients who are +' years and

older, especially for stro"e prevention (2indholm, #$$!. Thus, use of these

drugs as initial therapy in older patients probably should be restricted to

situations where there is another indication for their use !e.g., heart failure,

previous myocardial infarction, angina.# They still should be considered

alternative firstline agents in younger patients, where they appear to lessen

cardiovascular morbidity as well as other recommended drugs. Getabloc"ers

reduce the ris" of sudden death and recurrent myocardial infarction for

patients with an initial myocardial infarction. $C inhibitors also reduce the

ris" of subse8uent myocardial infarction and progression to heart failure for

patients who experience a large myocardial infarction associated with

impairment of left ventricular function. They also may reduce ris" for patients

with !or at high ris" for# cardiovascular disease (Heart 7utcomes Pre)ention

E)aluation 4tudy n)estigators, 'he, #$$$!.

9



ongacting dihydopyridine calcium antagonists have been shown to be

effective for patients age +' years or older with isolated systolic hypertension.

Coexisting medical conditions may also justify the use of one of these

classes of drugs. vidence from a recent large study refutes concerns about

increased ris" of myocardial infarction, cancer or gastrointestinal bleeding

from use of longacting calcium antagonists. However, data does suggest that

this class of drugs may be less effective in preventing heart failure (22H'

7icers, *oordinators or the 22H' *olla+orati)e "esearch Group, 'he,

#$$$!. The wor" group suggests these drugs be limited to those conditions

listed in $ppendix G, Therapies. 6ata supporting potential dangers of

calcium antagonists are limited to shortacting preparations !especially

nifedipine# that are not approved for the treatment of hypertension.

$ majority of patients will re8uire more than one drug for blood pressure

control. Combination therapies that include a diuretic are often effective,

lessen the ris" for side effects !by use of low doses of each component drug#,

and enhance adherence by simplification of the treatment program. *or

patients with chronic "idney disease, three or more drugs may be needed to

achieve goal. $lthough limited scientific evidence supports the use of

combination therapy as initial drug treatment for hypertension, several

observations favor such an approach (Gradman, #$1$!. Hypertension results

from the effects of multiple pressor mechanisms and drug monotherapy

usually targets only one of these. 7oreover, drug therapy targeted to only one

mechanism often triggers counterregulatory effects that limit overall

10



response. Gecause combination therapy targets more than one pressor

mechanism and limits counterregulatory effects, blood pressure response is

greater and control is achieved 8uic"er than with drug monotherapy. )n

addition, many drugs have doserelated side effects. ower doses of two

drugs may be better tolerated than higher doses of a single agent. %tudies also

show that the blood pressure lowering effect of combining drugs is predicted

onthe basis of additive effects and the overall response of using two drugs is

five times greater than the effect of doubling the dose of a single agent (Wald,

#$$9!. )n addition, a correlation between time ta"en to achieve blood pressure

control and clinical outcome has been observed. 9ne study involving primary

care clinics in Canada compared treatment using their current national

guidelines with a treatment algorithm that directed initial therapy with a low

dose diuretic4$C inhibitor or diuretic4$-G combination with subse8uent

uptitration of the combination as needed to control blood pressure (0eldman,

#$$9!. $fter six months, control rates were significantly higher with the

combination algorithm compared to the national guidelines approach, which

directed treatment with drug monotherapy and subse8uent dose uptitration of

the initial drug. Current guidelines (*ho+anian, #$$! suggest use of two

drugs as initial therapy when G3 is I 2'41' mmHg above the goal, which

consists of all patients with %tage 2 hypertension. 7ost effective two drug

combinations include a diuretic paired with one of the other recommended

firstline drugs. $ recent study demonstrated superior efficacy of an $C

inhibitor4dihydropyridine calcium antagonist combination compared to a

11



diuretic4$Cinhibitor combination (6amerson, #$$!. 7ore routine use of

initial therapy with combinations of drugs may improve control rates and

reduce morbidity and mortality from hypertension. %ingle pill combinations

can be used initially or to simplify the drug program after titration of

individual component drugs.

0. Change Treatment

9nce antihypertensive drug therapy is initiated, most patients should

return for followup and medication adjustments at least at monthly intervals

until blood pressure goal is reached. *ewer than &'( of patients with

hypertension will be controlled with a single drug. )f blood pressure goals are

not met, the clinician has three options for subse8uent therapy:

a. $dd a second drug from another class.

b. %ubstitute an agent from another class.

c. )ncrease the dose of the initial drug.

)ndividualiDed drug selection is based on several principles:

a. )f the initial response to one drug is ade8uate, continue the same drug. b. )f the response is partial on one agent, increase the dose or add a second

drug of a different class.

c. )f there is little response, substitute another single drug from a different

class.

d. Consider lowdose diuretic use early or as a first addition.

12



e. Consider loop diuretic agents instead of thiaDide or thiaDideli"e diuretics

when creatinine is greater than 2.' mg4d or estimated glomerular

filtration rate is less than /' m4min per 1./m2.

f. 6o not combine two drugs of the same class.

g. The use of combination agents can be effective.

*or most patients, two or more drugs in combination may be needed to

reach hypertension goals. %ystolic blood pressure control for adults with

cardiovascular comorbidities is poor !ong, 2''#. The combination of a

diuretic appropriate for level of renal function with an angiotensinconverting

enDyme inhibitor or angiotensin receptor bloc"er is often an effective two

drug program. $ diuretic $C inhibitor combination has been shown to

reduce both the macrovascular and microvascular complications of type 2

diabetes !$6J$FC Collaborative Kroup, 2''#. The combination of an

$C inhibitor with an angiotensin receptor bloc"er has little additional effect

on blood pressure compared to either monotherapy and may be associated

with increased ris" of adverse effects including renal dysfunction and

hyper"alemia !9FT$-KT )nvestigators, The, 2'';#0 however, this

combination is more effective than either monotherapy alone in reducing

proteinuria !LunD, 2'';#. The combination of a calcium channel antagonist

with an $C inhibitor is as effective or more effective than the traditional

combination of a diuretic with a betabloc"er in lowering blood pressure and

reducing cardiovascular events !6ahlMf, 2''&0 Chobanian, 2''/0 Gevan,

1AA/#.

G. Fursing planning for hypertension

13



Nur#ing Diagno#i#1

1. 6eficient Lnowledge related to the relationship between lifestyle choices and

the management of hypertension

Inter+ention# and Rationa!e#1

a. Teach patient that health beliefs and practices influence lifestyle choices.

Guild a trusting and sharing relationship between the patient and health

care team.

b. 7onitor blood pressure in the health care office and home. 7onitoring is

done by the nurse, patient, and4or family member. Glood pressure findings

may vary dependent on the lifestyle choices, time of day, and degree of

stress experienced by the patient.

c. 7onitor exercise and weight patterns.eight may be in excess of the

bodyNs needs and can lead to potential complications of therapy.

d. $ssess the degree of patient anger. %elfconcept changes when the

individual is physiologically and psychologically threatened as reflected

by ineffective coping and high blood pressure.

e. Teach the patient to report to the health care provider the use of herbal

products and 9TC medications prior to ta"ing them because they

fre8uently change the action of the hypertensive drugs. Herbal substances

are not regulated by the federal *ood and 6rug $dministration and may

vary in strength. 9TC medicines may interact with prescription

medications either by increasing or decreasing the therapeutic effect.

f. Teach the patient to monitor the amount of alcohol consumed per

day4wee" because many hypertensive drugs labels warn about the

14



consumption of alcohol. $lcohol consumption elevates arterial blood

pressure and adds OemptyP calories to the patientNs diet.g. Teach that smo"ing cessation is important. Cigarette, cigar, and pipe

smo"ing affects the cardiovascular system through the action of inhaled

nicotine.

2. *atigue related to biochemical changes due to chronic disease

Inter+ention# and Rationa!e# 1

a. )nstruct the patient4family about potential side effects of the prescribed

therapeutic agents to identify any areas of misunderstanding or

misinformation concerning the therapeutic plan.

b. )nstruct the patient to read medicine bottle labels and to follow the

directions for pulse and blood pressure assessment prior to ta"ing the dose

of medication to promote the therapeutic medication dose levels and the

safe physiological levels when administering the pharmaceutical

treatment.

c. )nstruct the patient to report and have approved by the health care

professional prior to ta"ing any 9TC medications, herbal substances,

alcohol, diet supplements, or stimulants to identify any untoward

reactions li"e fatigue between the therapeutic regime and other

substances.

d. 3lan rest periods to decrease fatigue level.

/. )mbalanced Futrition: 7ore than Gody -e8uirements related to excessive

caloric inta"e


a. 6iscuss with the patient realistic goals for weight reduction and an

exercise program. This plan is age dependent. eight is a modifiable

cause of high blood pressure. $ relationship between saturated fat and

cholesterol to weight is well established.

@. )mpaired Tissue 3erfusion related to resistance to blood flow

15




a. Teach combination of medications, diet, and exercise for the protection of

the target organs. Lnowledge and ownership of the treatment plan by the

patient will increase the patientNs motivation to modify lifestyle.

&. -is" of Foncompliance related to the medical treatment plan


a. Teaches and demonstrates a partnership with the patient4family so that the

treatment regimen is understood.

b. Teaches the goals of therapy and the dangerousness of a relapse in the

treatment plan. Compliance is a positive behavior that patients

demonstrate when therapeutic goals are mutually agreed on. Compliance

is a continuum of coordinated action.

+. %exual 6ysfunction related to disease and4or therapy


a. hen assisting with patient discussion of sexuality, teach that it is part of

the plan of care and may be discussed at any health care visit. The patient

needs reassurance that the information is confidential. )t is important that

the health care provider be educated concerning sexual health and

sexuality throughout the life span. The health care provider needs to "now

his or her feelings and beliefs concerning sexuality within the culture.

3atients want to "now if their feelings are normal versus abnormal

concerning this important information.

16



-*-FC%

%chwartD, K., Lerandi, H., uehr, 6., 9Connor, 3., 7argolis, L., -eddy, K.,

oolley, $., CanDanello, J., 3ereira, C., %chlichte, $. !2'1'#. Health *are

Guideline: Hypertension ;iagnosis and 'reatment. )nstitute for Clinical

%ystems )mprovement. *rom: www.icsi.org

Harley, $. Physiological *oncepts "elated to Nursing Practice. *rom:

http:44www.boo"dev.com43earson49sborn4dap4chapters4721Q9%G91'2/Q'

1Q%QC21.pdf

6e itt, ., R 3loeg, E. !2''+#. Critical appraisal of rigor in interpretive

phenomenological nursing research. Eournal of $dvanced Fursing, &&, 21&S

22A.

)ngle, . $. !2''1#. *actors assisting with client management of hypertension.

5npublished masterNs thesis, CarsonFewman College, Eefferson City, TF.

3eters, -. 7. !2''+#. The relationship of racism, chronic stress emotions, and blood

pressure. Eournal of Fursing %cholarship, /;, 2/@S2@'.

17

http://www.icsi.org/

http://www.icsi.org/



A""endi- A 1 Do#e of Antih%"erten#i+e Drug#

Drug HTN #tarting do#e

Diuretic#

Thia2ide T%"e

Chlorthalidone 12.&2& mg daily

ChlorothiaDide '.&1g once or twice daily

HydrochlorothiaDide 12.&2& mg daily

)ndapamide 1.2& mg daily

7etolaDone 2.&& mg daily

(oo"

GumetanideB '.&1 mg daily

thacrynic $cidB &'1'' mg daily

*urosemide @' mg twice daily

Torsemide & mg daily

Pota##ium3S"aring

$miloride & mg daily

plerenone &' mg daily

%pironolactone &'1'' mg daily

Triamterene &'1'' mg daily

Angioten#in3Con+erting En2%me Inhiitor#

GenaDepril 1' mg daily

Captopril 2& mg two to three times daily

nalapril & mg daily

*osinopril 1' mg daily

isinopril 1' mg daily

7oexipril .& mg daily

3erindopril @ mg daily

uinapril 1'2' mg daily

-amipril 2.& mg daily

Trandolapril 12 mg daily

Not a""ro+ed for h%"erten#ion

Angioten#in Rece"tor B!ocker# $ARB#&

Candesartan 1+ mg daily

prosartan +'' mg daily

)rbesartan 1&' mg daily

osartan &' mg daily

9lmesartan 2' mg daily

18



Telmisartan @' mg daily

Jalsartan ;'1+' mg daily

Beta3Adrenergic B!ocker#*ithout Intrin#ic S%m"athomimetic Acti+it%

$tenolol 2&&' mg daily

Getaxolol 1' mg daily

Gisoprolol 2.&& mg daily

7etoprolol %uccinate 2&1'' mg daily

7etoprolol Tartrate 2&&' mg twice daily

Fadolol @' mg daily

Febivolol & mg daily

3ropranolol @' mg twice daily

3ropranolol xtendedrelease ;' mg dailyTimolol 1' mg twice daily

*ith Intrini#ic S%m"athomimetic Acti+it%

$cebutolol @'' mg daily

3enbutolol 2' mg daily

3indolol & mg twice daily

ith $lphaGloc"ing $ctivity

Carvedilol +.2& mg twice daily

Carvedilol xtendedrelease 2' mg daily

abetalol 1'' mg twice dailyCa!cium Channe! B!ocker#

Fondihydropyridines

6iltiaDem - !2@ hour# 12' daily

Jerapamil - !2@ hour# 1;' daily

Dih%dro"%ridine#

$mlodipine & mg daily

*elodipine & mg daily

)sradipine 2.& mg twice daily

)sradipine - & mg daily

Ficardipine 2' mg three times daily Ficardipine xtendedrelease /' mg twice daily

Fifedipine /' mg twice daily

Fifedipine - /' mg daily

Fisoldipine - 1 mg daily

A!"ha3Adrenergic B!ocker#

6oxaDosin 1 mg daily

3raDosin 1 mg daily

TeraDosin 1 mg daily

Other Antih%"erten#i+e#

Central $lpha$ndrenertic $gonists

19



Clonidine '.1 mg twice daily

Clonidine TT% '.1 mg patch applied wee"ly

KuanabenD @ mg twice dailyKuanfacine 1 mg daily

7ethyldopa 2&' mg twice daily

Direct 4a#odi!ator#

HydralaDine 1' mg four times daily

7inoxidil & mg daily

Renin Inhiitor#

$lis"iren 1&' mg daily

A+ai!a!e Drug Comination

Drug HTN #tarting do#e

Ace Inhiitor5DiureticGenaDepril4HydrochlorothiaDide

Captopril4HydrochlorothiaDide

nalapril4HydrochlorothiaDide

*osinopril4HydrochlorothiaDide

isinopril4HydrochlorothiaDide

7oexipril4HydrochlorothiaDide

uinapril4HydrochlorothiaDide

Angioten#in Rece"tor B!ocker#5Diuretic

Candesartan4HydrochlorothiaDide

prosartan4HydrochlorothiaDide)rbesartan4HydrochlorothiaDide

osartan4HydrochlorothiaDide

9lmesartan4HydrochlorothiaDide

Telmisartan4HydrochlorothiaDide

Jalsartan4HydrochlrorothiaDide

Beta3Adrenergic B!ocker#5Diuretic#

$tenolol4Chlorthalidone

Gisoprolol4HydrochlorothiaDide

7etoprolol tartrate4HydrochlorothiaDide

3ropranolol4HydrochlorothiaDide )- 3ropranolol4HydrochlorothiaDide -

Diuretic Comination#

HydrochlorothiaDide4%pironolactone

Triamterene4HydrochlorothiaDide

HydrochlorothiaDide4$miloride

Refer to indi+idua! drug# for #tarting do#e#

Direct 4a#odi!ator#5Diuretic#

Drug HTN Starting Do#e

HydralaDine4HydrochlorothiaDide 2&42& mg twice daily

20



Centra! A!"ha5Andrenergic Agoni#t5Diuretic

7ethyldopa4HydrochlorothiaDide 2&'41& mg two or three times

daily

Ca!cium Channe! B!ocker5Ace Inhiitor

$mlodipine4GenaDepril 2.&41' mg daily

*elodipine4nalapril 2.&4& mg daily

Jerapamil4Trandolapril 1;'42 mg daily

Ca!cium Channe! B!ocker5Angioten#in Rece"tor B!ocker

$mlodipine4Telmistartan &4@' mg daily

$mlodipine49lmesartan &42' mg daily

$mlodipine4Jalsartan &41+' mg daily

Ca!cium Channe! B!ocker5Angioten#in Rece"tor B!ocker5Diuretic

$mlopidine4Jalsartan4HydrochlorothiaDide &41+'412.& mg daily

$mlopidine49lmesartan4HydrochlorothiaDide &42'412.& mg daily

Renin Inhiitor5Diuretic

$lis"iren4HydrochlorothiaDide 1&'412.& mg daily

Renin Inhiitor5Angioten#in Rece"tor B!ocker

$lis"iren4Jalsartan 1&'41+' mg daily

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drug therapy for high blood pressure

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