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8/17/2019 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
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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, #$$#/ ppel, 199%!
. Dietar% Inter+ention#
5se of a 6$%H !6ietary $pproaches to %top Hypertension# eating
plan has been shown in cohort studies to reduce incidence of congestive
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heart failure by 2&( and incidence of stro"e by 1( in women (0ung,
#$$!. )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, #$$1!.
(Whelton, 199/ Neaton, 199!
c. )oderation of A!coho! Intake
$lcohol consumption has complex effects on the cardiovascular
system. $lcohol consumption raises both systolic and diastolic pressures,
but its effects appear to be greater on systolic pressure. %ignificant
elevations in blood pressure have been shown in individuals who
consumed an average of at least three standard drin"s per day compared
with nondrin"ers. $lcoholism may cause hypertension, and an alcoholic
is less li"ely to respond to any hypertension treatment recommendations
(0riedman, 199$!. %ome persons may develop transitory hypertension
during the first days of detoxification. $lcohol is a concentrated calorie
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source that does not provide any nutrients, so reducing alcohol inta"e can
hasten weight reduction and may decrease triglyceride levels. $lthough
cohort studies suggest that modest alcohol consumption may reduce the
rate of myocardial ischemic events, alcohol use of up to 2 ounces per day
neither increases nor decreases total mortality or cardiovascular mortality
in those with hypertension (Beulens, #$$%!. 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, #$$%!. 9ther aerobic
activities !bi"ing, swimming, jogging, etc.# may be more enjoyable.
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-esistive isotonic activities, when done as the only form of exercise
training, are not recommended to lower blood pressure in hypertensive
patients. (World Hypertension 2eague, 1991!
e. Pota##ium
High dietary potassium inta"e is associated with lower blood pressure.
hile data from individual trials have been inconsistent, metaanalyses
have documented a bloodpressurelowering effect (ppel, #$$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
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)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:/&;+;.
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/. 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
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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,
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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, #$$!. Thus, use of these
drugs as initial therapy in older patients probably should be restricted to
situations where there is another indication for their use !e.g., heart failure,
previous myocardial infarction, angina.# They still should be considered
alternative firstline agents in younger patients, where they appear to lessen
cardiovascular morbidity as well as other recommended drugs. Getabloc"ers
reduce the ris" of sudden death and recurrent myocardial infarction for
patients with an initial myocardial infarction. $C inhibitors also reduce the
ris" of subse8uent myocardial infarction and progression to heart failure for
patients who experience a large myocardial infarction associated with
impairment of left ventricular function. They also may reduce ris" for patients
with !or at high ris" for# cardiovascular disease (Heart 7utcomes Pre)ention
E)aluation 4tudy n)estigators, 'he, #$$$!.
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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,
#$$$!. The wor" group suggests these drugs be limited to those conditions
listed in $ppendix G, Therapies. 6ata supporting potential dangers of
calcium antagonists are limited to shortacting preparations !especially
nifedipine# that are not approved for the treatment of hypertension.
$ majority of patients will re8uire more than one drug for blood pressure
control. Combination therapies that include a diuretic are often effective,
lessen the ris" for side effects !by use of low doses of each component drug#,
and enhance adherence by simplification of the treatment program. *or
patients with chronic "idney disease, three or more drugs may be needed to
achieve goal. $lthough limited scientific evidence supports the use of
combination therapy as initial drug treatment for hypertension, several
observations favor such an approach (Gradman, #$1$!. Hypertension results
from the effects of multiple pressor mechanisms and drug monotherapy
usually targets only one of these. 7oreover, drug therapy targeted to only one
mechanism often triggers counterregulatory effects that limit overall
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response. Gecause combination therapy targets more than one pressor
mechanism and limits counterregulatory effects, blood pressure response is
greater and control is achieved 8uic"er than with drug monotherapy. )n
addition, many drugs have doserelated side effects. ower doses of two
drugs may be better tolerated than higher doses of a single agent. %tudies also
show that the blood pressure lowering effect of combining drugs is predicted
onthe basis of additive effects and the overall response of using two drugs is
five times greater than the effect of doubling the dose of a single agent (Wald,
#$$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 $C
inhibitor4dihydropyridine calcium antagonist combination compared to a
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diuretic4$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.
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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
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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
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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
Inter+ention# and Rationa!e# 1
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
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Inter+ention# and Rationa!e# 1
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
Inter+ention# and Rationa!e# 1
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
Inter+ention# and Rationa!e# 1
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.
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-*-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@'.
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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
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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
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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
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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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