Pharmacological Treatment Options for Hypertension

First line agents:

  • Thiazide diuretic
  • Angiotensin converting enzyme inhibitor (ACEI)
  • Angiotensin receptor blocker (ARB)
  • Calcium channel blocker (CCB)
  • Beta blocker

Second line agents:

  • Alpha blockers
  • Vasodilators
  • Nitrates
  • Direct renin inhibitors
  • Central acting alpha agonists

Combination Therapy Advantages:

  • Multiple medications are often required to reach target levels, especially in patients with Type 2 diabetes.
  • Reduce pill burden with single combination.
  • Lower doses of multiple drugs may be better tolerated than higher doses of fewer drugs.
  • STITCH trial: Larger BP reductions, more patients at target BP with fixed dose combo versus monotherapy

Treatment of Resistant Hypertension:

  • Referral suggested to a health care provider with expertise in diagnosis and management of hypertension.
  • Defined as BP above target despite > 3 BP lowering drugs at optimal doses.
  • Preferably includes a diuretic.

Strategies to Improve Adherence to Pharmacotherapy

Assist your patient by:

  • Tailoring pill-taking to fit patient’s daily habits.
  • Simplifying medication regimens to once-daily dosing.
  • Replacing multiple pill antihypertensive combinations with single pill combinations.
  • Using unit-of-use packaging (of several medications to be taken together).
  • Using a multidisciplinary team approach to improve adherence to an antihypertensive prescription.

Assist your patient in getting more involved in their treatment regimen by:

  • Encouraging greater patient responsibility/autonomy in monitoring their blood pressure and adjusting their prescriptions.
  • Educating patients and their families about their disease and treatment regimens.


  • Assessing adherence to pharmacological and nonpharmacological therapy at every visit.
  • Encouraging adherence with therapy by out-of-office contact (either by phone or mail), particularly during the first three months of therapy.
  • Coordinating with health care team to improve monitoring of adherence with pharmacological and lifestyle. modification prescriptions
  • Utilizing electronic medication compliance aids.

Home Blood Pressure Monitoring:

  • Can be considered for ALL patients with hypertension, especially: Diabetes, Chronic kidney disease, Suspected non adherence, Demonstrated white coat effect, BP controlled in office, but not at home.
  • Requires adequate training.
  • Patient should be observed and given information about interpreting readings.

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