What to prescribe (and to whom) are questions of on-going debate and investigation. The following are some generally accepted recommendations:
For most patients without complicating conditions
Diuretics are usually recommended as first-line treatment for patients without complications either alone or together with an ACE inhibitor, ARB, beta-blocker, or calcium channel blocker. Diuretics are generally safe, effective, and less expensive than other high blood pressure medications.
There are reasons why medications other than diuretics would be selected first. See the following descriptions.
For older adults
Diuretics continue to be the best choice for most older adults. The initial dose in people over 65 should generally be half the dose used in younger adults. Blood pressure should be checked both while seated and standing because older adults may drop their blood pressure while standing.
Because of a concern for drug interactions and side effects, some physicians are reluctant to give high blood pressure drugs to elderly patients. The scientific information, however, strongly supports the use of diuretics or beta blockers in the elderly (including those with isolated systolic hypertension) to lower the risk of heart attack, stroke, and heart failure.
For patients with diabetes
Studies are now suggesting that people with diabetes need to control their blood pressure to 130/80 mm Hg or lower. This is to protect the heart and help prevent other complications common to both diseases. In general, ACE inhibitors and ARBs are the first choice for people with diabetes, since they also appear to protect the kidneys. In many cases, however, combinations are required to achieve blood pressure goals. In such cases, low-dose diuretics or calcium-channel blockers are added as needed.
For patients with isolated systolic hypertension
Isolated high systolic pressure is usually treated with a diuretic. A long-acting calcium-channel blocker may be an alternative, although some experts believe that ACE inhibitors or ARBs are proving to be the best choice in this group.
For patients with heart failure
People with heart failure generally should be given ACE inhibitors, often in combination with a diuretic.
For patients who have had a heart attack
ACE inhibitors and beta blockers are generally used following a heart attack.
For patients who are pregnant
Most women who develop high blood pressure only during pregnancy (gestational hypertension) are at low risk for preeclampsia and require no treatment, other than monitoring. Treating pregnant women who have chronic, mild high blood pressure is probably not necessary, although no large studies have been done to confirm this.
Many of the standard high blood pressure drugs, particularly ACE inhibitors and ARBs, have seriously harmful effects to a fetus, including kidney disease and fatalities. Beta-blockers should not be used during the early stages of pregnancy -- later use can be considered by your obstetrician. Methyldopa has been the most researched blood pressure medication during pregnancy and may be selected by your doctor if you are diagnosed with high blood pressure while pregnant.
Treatment for preeclampsia ranges from monitoring to emergency delivery of the baby, depending on severity. Preeclampsia does not respond well to standard drug treatments. Treatment using magnesium sulfate is commonly used to prevent complications (like seizures) from preeclampsia.
Review Date: June 3, 2003
Reviewed By: Jacqueline A. Hart, M.D., Department of Internal Medicine,
Newton-Wellesley Hospital, Harvard University and Senior Medical Editor,
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