This is snippet I am working on to ease the medication minutia we need to process. We use this to very quickly enter current and planned medications into our EHR. It also helps give structure to the treatment approach which sometimes is overlooked in the multitude of daily decisions.
This is a work in progress and not to be relied on for medical reference, advice etc.
I have included a link to a sample antihypertension medication table as a starting point. Minimal proofing done please don't rely on it for your patients until you have edited it appropriately.
{formtoggle: default=yes; name=Thiazides}Thiazide diuretics:
{dbselect: SELECT Name, mg, Tags, Note, Cost FROM HTN WHERE includes(Tags, "thiazide") ORDER BY Cost ASC; space=1ZaCJdG22Vog5nZBy4XpAg; menu=yes; name=Thiazide}
{=Thiazide["name"]} {=Thiazide["mg"]}mg {formmenu: default=QD; BID; TID; cols=6} {note} Note: {=Thiazide["note"]}{endnote}
{endformtoggle}
{formtoggle: name=ACEi; default=yes}ACE Inhibitors: {note}Avoid with ARBs. Not first choice in black population{endnote}
{dbselect: SELECT Name, mg, Tags, Note, Cost FROM HTN WHERE includes(Tags, "ACEi") ORDER BY Cost ASC; space=1ZaCJdG22Vog5nZBy4XpAg; menu=yes; name=ACEi; multiple=no}
{=ACEi["name"]} {=ACEi["mg"]}mg {formmenu: default=QD; BID; TID; ; cols=6} {note}{=ACEi["note"]}{endnote}
{endformtoggle}
{formtoggle: name=ARB; default=yes}Angiotensin Receptor Blockers (ARB) {note}Avoid with ACEi{endnote}
{dbselect: SELECT Name, mg, Tags, Note, Cost FROM HTN WHERE includes(Tags, "ARB") ORDER BY Cost ASC; space=1ZaCJdG22Vog5nZBy4XpAg; menu=yes; name=ARB}
{=ARB["name"]} {=ARB["mg"]}mg {formmenu: default=QD; BID; TID; cols=6} {note}{=ARB["note"]}{endnote}
{endformtoggle}
{formtoggle: name=CCB; default=yes}CCB (Calcium Channel Blockers) {note}First choice in elderly and black populations{endnote}
{dbselect: SELECT Name, mg, Tags, Note, Cost FROM HTN WHERE includes(Tags, "CCB") ORDER BY Cost ASC; space=1ZaCJdG22Vog5nZBy4XpAg; menu=yes; name=CCB}
{=CCB["name"]} {=CCB["mg"]}mg {formmenu: default=QD; BID; TID} {note}{=CCB["note"]}{endnote}{endformtoggle}
{note} or calcium-channel blockers, or a combination of two different drugs from these classes (excluding the combination of ACE inhibitors and angiotensin-II receptor antagonists). Aliskiren, a direct renin inhibitor, is also available; however, its place in the treatment pathway is not yet clear due to concerns about risks in combination with ACE inhibitors or angiotensin-II receptor antagonists, and in the settings of diabetes or renal impairment, and it is not considered to be a preferred option.[6]
In the general black population, including those with diabetes, a thiazide (or thiazide-like) diuretic or a calcium-channel blocker is recommended as initial pharmacologic therapy.[2] [5] The recommendation is derived from a prespecified subgroup analysis of black patients, 46% of whom had diabetes, in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) trial.[86] [87]
In patients with diabetes who have increased albumin excretion, ACE inhibitors or angiotensin-II receptor antagonists are recommended. The ALLHAT study showed that chlorthalidone, amlodipine, or lisinopril were co-equal for mild hypertension in type 2 diabetes.[86] ACE inhibitors are renoprotective, decreasing the progression of proteinuria in patients with diabetes.[88] Sleep-time BP is the most significant independent prognostic marker of cardiovascular events in diabetes.
Comorbid coronary artery disease
Beta-blockers are first-line. Beta-blockers have proven beneficial in patients with chronic stable angina, post-myocardial infarction, or congestive heart failure (CHF), in patients with coronary artery disease (CAD) undergoing surgery, or in patients with hypertrophic obstructive cardiomyopathy.[89] [90] [91] [92] [93]
ACE inhibitors have been shown in some trials to decrease cardiovascular events, while other studies have not demonstrated a benefit for ACE inhibitors in the setting of stable CAD with normal left ventricular function.[94] [95] [96] Beta-blockers, ACE inhibitors, or angiotensin-II receptor antagonists can be used as first-line for compelling indications (e.g., previous myocardial infarction, stable angina).[2] [5] Other drugs such as dihydropyridine calcium-channel blockers, thiazide diuretics, and/or mineralocorticoid receptor antagonists are added as required to further control hypertension.
Many patients with CAD also take nitrates, which act as exogenous nitric oxide donor. Modest reductions in systolic BP can be observed, but the Food and Drug Administration has not approved the use of nitrates solely as antihypertensive therapy.[13]
Comorbid heart failure with reduced ejection fraction
In patients with comorbid heart failure with reduced ejection fraction (<40%), an ACE inhibitor (or an angiotensin-II receptor antagonist if not tolerated) plus a beta-blocker with or without an aldosterone antagonist is used.
ACE inhibition has been shown to convey a survival advantage in patients with CHF.[90] [97] Angiotensin-II receptor antagonists also decrease morbidity and mortality.[98] [99] Compared with ACE inhibitors, angiotensin-II receptor antagonists were equivalent, but not superior, in the treatment of patients with CHF.[100] [101]
Beta-blockers have proven mortality benefits in patients with chronic CHF.[91] [92]
Aldosterone antagonists should be given to patients with heart failure and ejection fraction under 35% who are taking optimized ACE inhibitor or angiotensin-II receptor antagonist plus beta-blocker treatment, who still require antihypertensive therapy. Blockade of aldosterone has been associated with decreased end-organ fibrosis.[102]
Diuretics (nonaldosterone) confer no mortality benefit for patients with CHF. However, they are frequently used to relieve symptoms of fluid overload.
The combination of hydralazine and a nitrate (e.g., isosorbide dinitrate/hydralazine) has been shown to be of benefit for self-defined African Americans already taking ACE inhibitors, beta-blockers, and aldosterone antagonists, as well as in all patients with CHF who are intolerant of both ACE inhibitors and angiotensin-II receptor antagonists.[103] [104]
Nondihydropyridine calcium-channel blockers are not recommended for the treatment of hypertension in adults with heart failure with reduced ejection fraction.[5]
Sacubitril/valsartan and ivabradine are newer drugs also used for chronic heart failure.
Comorbid heart failure with preserved ejection fraction
Diuretics should be used to control hypertension in patients with comorbid heart failure with preserved ejection fraction (>45%) who present with symptoms of volume overload.[5] If hypertension persists after the management of volume overload, ACE inhibitors or angiotensin-II receptor antagonists and beta-blockers should be used and titrated to achieve the target BP goal.
Comorbid left ventricular hypertrophy
ACE inhibition has proven beneficial across a myriad of cardiovascular disease states including CHF and left ventricular hypertrophy (LVH).[94] [95] An angiotensin-II receptor antagonist is first choice for comorbid LVH. Angiotensin-II receptor antagonists have been shown to decrease morbidity and mortality in patients with hypertension and LVH.[98]
Comorbid renal disease
An ACE inhibitor is first choice for comorbid renal disease (chronic kidney disease stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/day or ≥300 mg/g albumin-to-creatinine ratio or equivalent in the first morning void]).[5] If an ACE inhibitor is not tolerated, an angiotensin-II receptor antagonist can be used.
Continuing ACE inhibitor or angiotensin-II receptor antagonist therapy may be associated with cardiovascular benefit as kidney function declines.[105]
Second-choice options are a calcium-channel blocker or thiazide diuretic. A non-dihydropyridine calcium-channel blocker (i.e., diltiazem, verapamil) may be indicated if there is proteinuria.[106]
Spironolactone may further reduce proteinuria when added to an ACE inhibitor or angiotensin-II receptor antagonist, but also raises the risk of hyperkalemia.[107] [108] Spironolactone is usually added to an ACE inhibitor, or angiotensin-II receptor antagonist, after a thiazide diuretic has been added to minimize hyperkalemia.
Comorbid atrial fibrillation
First choice is a beta-blocker. Second choice is a nondihydropyridine calcium-channel blocker.
Evidence from post-hoc analyses suggest that angiotensin-II receptor antagonists and ACE inhibitors do not prevent the occurrence or the recurrence of atrial fibrillation.[109] [110] [111] [112] However, more recent guidelines note that use of ACE inhibitors and angiotensin-II receptor antagonists may be effective in the prevention of atrial fibrillation.[5] [113] More investigation is needed.
Comorbid benign prostatic hypertrophy
The ALLHAT study conclusively demonstrated that alpha-blockers should not be a first-line antihypertensive therapy for patients with symptomatic benign prostatic hypertrophy (BPH). In these patients, the preferred first-line antihypertensive options are the same as for most other groups (i.e., thiazide-like diuretics, ACE inhibitors, angiotensin-II receptor antagonists, and calcium-channel blockers), and the alpha-blocker indication is simply to treat the BPH symptoms.
Comorbid Raynaud disease, peripheral vascular disease, or coronary artery spasm
Calcium-channel blockers are first choice. In addition to vascular disease, calcium-channel blockers are also useful for persistent angina or stroke prevention.[114] [115]
Stage 2 hypertension
The ACC/AHA guidelines define stage 2 hypertension as BP ≥140/90 mmHg.[5] The European Society of Cardiology guidelines define this category of BP in three grades:[2]
Grade 1 hypertension BP 140-159/90-99 mmHg
Grade 2 hypertension 160-179/100-109 mmHg
Grade 3 hypertension ≥180 mmHg/110 mmHg.
Patients presenting with stage 2 hypertension will require more than one drug for BP control. Therefore, the initiation of two concurrent antihypertensives of different classes is recommended.
The combination of a nondihydropyridine calcium-channel blocker with a beta-blocker should be avoided, because of an increased risk of high-degree atrioventricular block.
Recalcitrant (resistant) hypertension
Recalcitrant (resistant) hypertension is defined as above-goal elevated BP in a patient taking three antihypertensive agents (commonly including a long-acting calcium-channel blocker, an ACE inhibitor or angiotensin-II receptor antagonist, and a diuretic) at maximally tolerated doses.[63] Managing recalcitrant hypertension requires expertise. Frequently requiring multiple antihypertensive agents, patients must be observed and counseled regarding adverse effects, medication adherence, potential drug-drug interactions, and metabolic abnormalities. Infrequently, patients will require a screen for secondary causes of hypertension.
Representative agents of the main treatment class options, including ACE inhibitors, angiotensin-II receptor antagonists, and calcium-channel blockers, should be maximized. An optimally dosed thiazide-like diuretic, such as chlorthalidone or indapamide, should be used over hydrochlorothiazide.[63] ACE inhibitors, angiotensin-II receptor antagonists, and/or direct renin inhibitors should not be used together due to the risk of acute renal failure.
The fourth-line drug option is generally spironolactone. Eplerenone can be used as an alternative. Spironolactone and eplerenone are contraindicated in patients with hyperkalemia. Caution should be used in patients with renal impairment; either a dose adjustment may be required, or the drug may be contraindicated depending on the severity of renal impairment, indication for use (i.e., hypertension versus heart failure), and local guidance. Concomitant administration with potassium-sparing diuretics is contraindicated.
Otherwise, a safe fourth- or fifth-line option is a peripheral adrenergic blocker. Hydralazine is a less-preferred option due its twice-daily dose requirement and increased risk of edema with simultaneous calcium-channel blocker treatment. Minoxidil is rarely required in patients with advanced chronic kidney disease and its use requires some expertise in anticipating and managing side-effects of fluid retention. Combined alpha- and beta-blockers (e.g., carvedilol, labetalol) are considerations. Additionally, physicians with expertise in managing difficult-to-control hypertension have had niche success using a combination of a dihydropyridine calcium-channel blocker plus a nondihydropyridine calcium-channel blocker (e.g., amlodipine plus diltiazem). Clonidine is generally avoided because of its side-effect profile.
The most important principles for managing challenging hypertension are:
Promotion of medication adherence using the principle of pill reduction (i.e., use of single pill, fixed-dose combination formulations or avoidance of twice-daily dose regimens when possible)
Maximizing the dose of the diuretic (thiazide or thiazide-like)
Use of spironolactone or eplerenone as a fourth drug when possible.[116]
It is also important to question the patient's alcohol use and offer lifestyle counseling.
Referral to a specialist in hypertension should be considered.
Older adults
In the oldest adult patients, many physicians are reluctant to treat hypertension in accordance with usual BP goals, for a number of reasons, including concerns about fall risk, drug interactions, adverse effects, and lack of benefit in mortality reduction. Previous literature reviews and meta-analysis demonstrated reductions in stroke, heart failure, and cardiovascular events in much older adults without reaching mortality benefit.[117] [118] However, the SPRINT trial found that treating ambulatory adults ages 75 years or older to a systolic BP target of <120 mmHg (as measured by AOBP) resulted in significantly lower rates of fatal and nonfatal major cardiovascular events and death from any cause, compared with a systolic BP target of <140 mmHg.[71] The SPRINT trial also found that intensive BP control did not result in any adverse effects on cognition: the risk of mild cognitive impairment and the combined rate of mild cognitive impairment or probable dementia was reduced in patients treated to a systolic BP target of <120 mmHg; however, the incidence of probable dementia was not reduced.[119] Patients with orthostasis at enrollment, patients with dementia, and those resident in a nursing home were excluded from the trial. One meta-analysis of randomized controlled trials (including SPRINT) found that pharmacologic treatment of hypertension in adults aged over 60 does not worsen cognition, and may reduce cognitive decline.[120] Another meta-analysis looking at the effects of intensive BP-lowering treatment on orthostatic hypotension found that intensive treatment of BP lowers risk of orthostatic hypotension (not raises it), and this finding was consistent regardless of age.[121]
The 2017 ACC/AHA guidelines recommend a systolic BP goal of <130 mmHg for noninstitutionalized ambulatory community-dwelling adults. For older adults ≥65 years of age with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs.[5]
European guidelines recommend a BP target of <140/90 mmHg in all patients including independent older patients and, if treatment is tolerated, a BP target of ≤130/80 mmHg in most patients.[2] UK guidelines from the National Institute for Health and Care Excellence recommmend a BP target of <150/90 mmHg for patients ages 80 years and over.[122]
The JNC 8 guideline recommends initiating pharmacologic therapy for patients aged ≥60 years at systolic BP ≥150 mmHg or diastolic BP ≥90 mmHg, and to treat to a systolic BP goal of <150 mmHg and a diastolic BP goal of <90 mmHg.[3]{endnote}