MANY PATIENTS WITH UNCOMPLICATED HYPERTENSION will need two or more medications to reach blood pressure (BP) goals. Comorbidities often drive medication combination choices, such as an angiotensin converting enzyme inhibitors (ACEI) plus beta-blocker in some patients with heart failure or after a heart attack. Emphasize lifestyle changes, assess adherence and check accuracy of BP measurements if one medication isn't enough for UNcomplicated hypertension.
Recommend combining first-line antihypertensive medications. An ACEI or ARB, calcium channel blocker, or thiazide to lower blood pressure and reduce cardiovascular (CV) risk. Weigh options. For example, chlorthalidone is longer-acting and has better cardiovascular (CV) outcomes than hydrochlorothiazide. But available only in combination products with atenolol or azilsartan. Explain that combining moderate doses of first-line medications may control blood pressure better than titrating the dose of one medication and may limit side effects. If needed, suggest combining three first-line medications.
Advise adding second-line antihypertensive medication if first-line combinations aren't enough or aren't tolerated. Think about comorbidities, side effects, etc. For example, suggest spironolactone next in many patients, especially those with hypokalemia, a beta-blocker (metoprolol, etc) for migraine prophylaxis or an alpha-blocker (doxazosin, etc) for benign prostatic hyperplasia (BPH). Recommend saving vasodilators (hydralazine, etc) or alpha-2 agonists (clonidine, etc) as a last resort due to adherence, side effects, etc.
Generally avoid combination of BP medications with similar mechanisms, especially an ACEI plus an ARB or aliskiren. These combinations can cause syncope and renal impairment and they lack cardiovascular benefit. But explain it's okay to use a dihydropyridine CCB (amlodipine, etc) with a NONdihydropyridine CCB (diltiazem, verapamil) if options are limited, such as in chronic kidney disease with resistant hypertension. For further information, see notes "Overview of hypertension" AND "Management of severe hypertension in adults".
REFERENCES
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Whelton, P.K., Carey, with others (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Journal of the American College of Cardiology, [online] 71(19), pp.e127–e248. Available at: http://www.onlinejacc.org/content/early/2017/11/04/j.jacc.2017.11.006
Qaseem, A., Wilt, T.J., Rich, R., Humphrey, L.L., Frost, J. and Forciea, M.A. (2017). Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians. Annals of Internal Medicine, 166(6), p.430. Available at: https://www.acpjournals.org/doi/10.7326/M16-1785?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
Law, M.R. (2003). Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ, 326(7404), pp.1427–0. Available at: https://www.bmj.com/content/326/7404/1427