---

Hypertension: Standard Treatment Protocol, Drug Changes & Investigations

---

1. Classification of Blood Pressure (ACC/AHA 2017)

---

2. Initial Approach - When to Start Treatment

---

3. Non-Pharmacological (Lifestyle) Treatment - MANDATORY First Step

• Harrison's Principles of Internal Medicine 22E, p. 2184-2185

---

4. Pharmacological Treatment - First-Line Drugs

1. Calcium-Channel Blockers (CCBs)
2. ACE Inhibitors (ACEi) or Angiotensin Receptor Blockers (ARBs)
3. Thiazide or Thiazide-like Diuretics

Beta-blockers are no longer recommended as initial therapy. They are less effective for stroke prevention compared to first-line agents, though they remain useful in patients with heart failure or ischemic heart disease.

• Goldman-Cecil Medicine, p. 750

First-Line Drug Doses

---

5. Compelling Indications - Disease-Specific Drug Choices

• National Kidney Foundation Primer on Kidney Diseases, 8e, p. 691

---

6. BP Targets

---

7. Step-Up Therapy - When and How to Change the Drug

Indications to Change or Add a Drug

1. BP not at target after 4-6 weeks at adequate dose
2. Significant side effects from current drug
3. Contraindication develops (e.g., ACEi causing angioedema - switch to ARB)
4. New comorbidity that favors a different class (e.g., MI develops - add beta-blocker)
5. Resistant hypertension (BP uncontrolled on 3 drugs including a diuretic at max doses)

Step Therapy Protocol

STEP 1: Lifestyle modification alone
    (if not at target in 3-6 months, or immediate drug Rx if high-risk)

STEP 2: Start 1-2 first-line drugs (ACEi/ARB + CCB, or + thiazide)
    - Reassess in 4-6 weeks

STEP 3: Increase dose of existing drug OR add second first-line drug
    - Preferred combinations: ACEi/ARB + CCB, or ACEi/ARB + thiazide
    - Avoid: ACEi + ARB together (increased renal/hyperkalemia risk)

STEP 4: 3-drug combination (ACEi/ARB + CCB + thiazide diuretic)
    - If still uncontrolled = RESISTANT HYPERTENSION

STEP 5 (Resistant HTN): Add spironolactone 25-50 mg/day
    (most effective 4th-line agent; check K+/eGFR first)
    Alternative: amiloride, doxazosin, or clonidine

When switching due to side effects:

• ACEi cough → switch to ARB
• ACEi/ARB angioedema → switch to ARB (for ACEi angioedema) - but if severe, avoid both
• CCB ankle edema → add ACEi/ARB (reduces edema) or switch to non-DHP CCB
• Thiazide hyperkalemia/gout → switch to another class

• Goldman-Cecil Medicine, p. 751

---

8. Monitoring After Starting/Changing Treatment

• Creatinine rise >30% above baseline on ACEi/ARB (suggests bilateral renal artery stenosis)
• Potassium >5.5 mEq/L on ACEi/ARB/MRA
• Symptomatic hypotension

---

9. Investigations

Baseline (All Patients at Diagnosis)

For Target Organ Damage Assessment

Investigations for Secondary Hypertension

---

10. Special Situations

---

• Harrison's Principles of Internal Medicine 22E (2025), Chapter 283 & 288
• Goldman-Cecil Medicine, Chapter 64
• National Kidney Foundation Primer on Kidney Diseases, 8e, Chapter 64
• ACC/AHA 2017 Hypertension Guidelines

---

Next Step: BP 150/90 on Amlodipine 5mg + Telmisartan 40mg

First - Assess the Situation

---

The Actual Next Step - Two Parallel Options

Option A (Preferred): Uptitrate Both Current Drugs

• Reassess BP after 4-6 weeks at max doses.

---

Option B: Add a Thiazide Diuretic (3-Drug Combination)

• BP is significantly elevated (as here, 150/90 is 20/10 above target)
• Patient has high ASCVD risk, diabetes, CKD, or established CVD
• Or you want faster control

• Katzung's Basic & Clinical Pharmacology, 16th Edition, p. 291

---

Practical Decision Tree

BP 150/90 on Amlo 5mg + Telmisartan 40mg
             |
             v
    Confirm adherence + correct measurement
             |
             v
     Choose ONE of:
    /                  \
Uptitrate both        Add Chlorthalidone
Amlo → 10mg          12.5-25mg OD
Telmi → 80mg         (keep current doses
                      OR also uptitrate)
             |
             v
     Reassess in 4-6 weeks
             |
      Still not at target?
             |
             v
     3-Drug max dose combo:
  Amlo 10mg + Telmi 80mg + Chlorthalidone 25mg
             |
      Still uncontrolled?
             |
             v
    RESISTANT HYPERTENSION
    → Investigate secondary causes
    → Add spironolactone 25-50mg OD as 4th agent

---

When Adding Chlorthalidone - Monitor

---

Key Points

• Do NOT combine ACEi + ARB - doubled RAAS blockade increases renal failure and hyperkalemia risk with no added BP benefit
• Beta-blockers are not first-line for uncomplicated hypertension - only add if co-existing ischemic heart disease, heart failure, or arrhythmia
• If telmisartan is causing side effects (rare: dizziness, hyperkalemia), switch to another ARB (e.g., losartan) rather than stopping the class
• If the patient is Black/African, diuretics and CCBs are more effective; ARBs/ACEi are relatively less effective as monotherapy