Treating hypertension in patients with medical comorbidities

• Published in: BMJ (Online) Vol. 352; no. 8045; p. i101
• Main Authors: Kennard, Lucinda, O’Shaughnessy, Kevin M
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group LTD 16-02-2016
• Subjects: Antihypertensive Agents - therapeutic use; Asthma; Blood pressure; Chronic obstructive pulmonary disease; Comorbidity; Diabetes; Diuretics; Drug dosages; Electrolytes; Heart failure; Humans; Hypertension; Hypertension - drug therapy; Kidney diseases; Mortality; Older people; Potassium; Practice Guidelines as Topic; Prescription drugs; Substance abuse treatment; United Kingdom; United Kingdom > UK
• ISSN: 1756-1833; 0959-8138; 1756-1833
• DOI: 10.1136/bmj.i101

Summary of first line treatment in patients with hypertension and comorbidities Chronic kidney disease Diabetes status and urinary albumin:creatinine ratio (ACR) guide appropriate treatment for hypertension: use an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) as first line treatment if a non-diabetic patient has ACR >30 mg/mmol or if a diabetic patient has ACR >3 mg/mmol Type 1 diabetes Treat hypertension with an ACEI (such as lisinopril) or ARB (such as losartan), followed by a low dose thiazide diuretic or a thiazide-like diuretic (such as chlortalidone) or a long acting calcium channel blocker (such as amlodipine) as second line Type 2 diabetes Treat hypertension with an ACEI as first line, except for black patients, for whom an ACEI plus a long acting calcium channel blocker or thiazide or thiazide-like diuretic should be first line Heart failure Hypertensive patients already taking an ACEI or ARB plus a β blocker, and whose blood pressure is not controlled, should also be given a thiazide or thiazide-like diuretic Elderly patients treated for hypertension Monitor for postural hypotension, especially if they are taking α blockers and after starting any new antihypertensive drug Asthma or chronic obstructive pulmonary disease (COPD) β blockers are no longer first line treatment for hypertension and should not be used routinely; if they are necessary in COPD, consider a low dose cardioselective β blocker (such as bisoprolol) with close monitoring of respiratory function Pain relief In patients taking an ACEI or ARB, if non-steroidal anti-inflammatory drugs (NSAIDs) are unavoidable, use short acting NSAIDs (such as ibuprofen) and monitor creatinine and electrolyte levels Hypertensive women of child bearing age Avoid use of ACEI and ARB and use a dihydropyridine calcium channel blocker as first line treatment (or a β blocker such as labetalol if they are pregnant) Box 2: