Treatment of hypertension

Doctors consider several factors before starting the treatment of hypertension. These factors include how high your blood pressure is, other medical conditions you may already have, your age, your gender, the cause of your hypertension and your risk of developing stroke and heart disease. Treatment of hypertension aims to prevent complications of hypertension.

Stage 1 hypertension If you have stage1 hypertension but otherwise healthy, your doctor may encourage lifestyle changes, such as:

  • having a healthier diet by:
  • eating fewer foods containing sugar, salt (restricting your salt intake to less than 6g a day) and saturated fat
  • eating more fruits and vegetables, oily fish rich in omega 3 fatty acids, such as salmon, mackerel and sardines
  • cutting down on alcohol intake to recommended levels
  • drinking less coffee and other caffeinated drinks like cola
  • losing weight if you are overweight or obese
  • quitting smoking. This may not have a direct impact on your blood pressure, but it does reduce the risk of complications like heart disease and stroke.
  • regular exercise like walking, cycling or swimming off at least 30 minutes a day, a minimum of five times a week. Aerobic exercises are also good as it gets your heart pumping
  • managing stress using relaxation therapies, such as yoga and meditation
treatment of hypertension
treatment of hypertension

If you have stage 1 hypertension and other cardiovascular risk factors such as atherosclerosis, or obesity, diabetes, your doctor may start you on a medication to protect your kidneys, heart, and other organs from potential damage.

Stage 2: Doctors usually start treatment of hypertension with medication

Severe hypertension needs urgent medical treatment. To bring the blood pressure down as quickly as possible, you may be given an anti-hypertensive that is an injection.


Medications used in the treatment of hypertension

Many different classes of drugs that work in different ways are used in the treatment of hypertension. The medication your doctor decides to use in treating your hypertension depends on several factors which includes your age, the other medicines you take, other medical conditions like diabetes and kidney disease, how high your blood pressure is, your racial group, your risk of developing heart disease, if you are pregnant and specific side effects and how prone you are to developing that side-effect for example fluid retention (which is when you builds up fluid somewhere in the body), causing swelling.

Your doctor may prescribe you a combination of medicines to control your high blood pressure and it may take time to find out which medicine or which combination of medicines works best for you


Angiotensin-converting enzyme inhibitors (ACE inhibitors)

Angiotensin II is a chemical in your body that enters your blood stream and causes your blood vessels to begin to constrict. This thickens and stiffens the walls of your blood vessels and heart thereby increasing the resistance of the vessels to free flow of blood through them. It also causes a hormone in your body to make your body retain water. More fluid or sodium and water in your body together with the restricted space will cause your blood pressure to rise. ACE inhibitors work by blocking the production of this chemical hence the blood vessels relax and widen, allowing blood to flow through with less resistance. It also reduces the volume of fluid and ultimately lower your blood pressure.

ACE inhibitors are recommended for people who are under 55 or who are not of African Caribbean origin. However, those over 55 or of African Caribbean origin can have ACE inhibitor as a second or third medicine. Your doctor can also prescribe you with ACE inhibitors if you have ­diabetes or kidney disease as well as high blood pressure. This is because there is some evidence to show that they can protect your kidneys.

If you are pregnant, breastfeeding or planning to become pregnant, you should not be given an ACE inhibitor.

Examples of ACE inhibitors are Perindopril, Ramipril, Enalapril, Fosinopril, Lisinopril, Captopril, Imidapril, Cilazapril, Trandolapril, Moexipril and Quinapril. Notice how these medicines have names that end in “pril”.         

The most commonly reported side-effect of ACE inhibitors is a persistent dry cough. If this happens to you, your doctor may change you to another medicine called an angiotensin receptor blocker (ARB). ARBs work in a similar way to ACE inhibitors but do not tend to cause a cough.

Some other side-effects of ACE inhibitors can include tiredness, weakness, rash, headaches, dizziness, and changes to your sense of taste.

Sometimes but very rarely, ACE inhibitor can cause angioedema which is an allergic reaction that causes swelling around the eyes, lips and tongue, hands, feet and genitals. In severe cases, the swelling can involve the inside of your throat and bowels. If it affects your throat, this can make you have breathing or swallowing difficulty.  You must contact your doctor immediately if you experience this.

It is important that you check with your doctor before taking other medicines in combination with ACE ­inhibitors. This is especially important when buying over-the-counter remedies as your doctor would consider your existing medicines before prescribing a new one.

Most blood pressure medication is taken for a very long time. You should also keep taking your medication even if you think your blood pressure is now controlled as stopping it could put your health at risk

You may require closer monitoring if you start taking an ACE inhibitor while already taking a diuretic because your first dose of an ACE inhibitor can sometimes cause a sudden drop in your blood pressure.


Angiotensin-II receptor blockers (ARBs)

Angiotensin II is a chemical in your body that enters your blood stream and causes your blood vessels to begin to constrict and that thickens and stiffens the walls of your blood vessels and heart. It also causes a hormone in your body to make your body retain water.

More fluid or sodium and water in your body together with the restricted space will cause your blood pressure to rise. ARBs work by blocking the production of this chemical hence the blood hence they relax and widen blood vessels and allows blood to flow through. It also reduces the volume of fluid and ultimately lowers your blood pressure.

ARBs are recommended for people who are under 55 or who are not of African Caribbean origin. However, those over 55 or of African Caribbean origin can have ARBs as a second or third medicine. Your doctor can also prescribe you with ARBs if you have ­diabetes or kidney disease as well as high blood pressure. This is because there is some evidence to show that they can protect your kidneys.

If you are pregnant, breastfeeding or planning to become pregnant, you should not be given ARBs.

Examples of ARBs are Irbesartan, Telmisartan, Olmesartan, Candesartan, Eprosartan, Losartan and Valsartan. Notice how these medicines have names that end in “sartan”.     

Angiotensin-II receptor antagonists work in a similar way to ACE inhibitors but does not cause cough. Your doctor may change you from an ACE inhibitor to an angiotensin receptor blocker (ARB) if you experience cough from ACE inhibitor.

Side-effects of ARBs can include headaches, dizziness, and cold or flu-like symptoms.

Sometimes but very rarely, ARBs can cause angioedema which is an allergic reaction that causes swelling around the eyes, lips and tongue, hands, feet and genitals. In severe cases, the swelling can involve the inside of your throat and bowels. If it affects your throat, this can make you have breathing or swallowing difficulty.  You must contact your doctor immediately if you experience this.      

It is important that you check with your doctor before taking other medicines in combination with ARBs. This is especially important when buying over-the-counter remedies as your doctor would consider your existing medicines before prescribing a new one.

Most blood pressure medication is taken for a very long time. You should also keep taking your medication even if you think your blood pressure is now controlled as stopping it could put your health at risk


Calcium-channel blockers (CCBs)

Calcium narrows your blood vessels and causes your blood pressure to rise. Calcium-channel blockers (CCBs) lower your blood pressure by preventing calcium from entering heart cells and the muscle cells within the blood vessel walls. This blocks the effects of calcium on your blood ­vessels and helps your blood vessel walls relax and widen, making it easier for blood to flow through.

Calcium-channel blockers (CCBs) are of different types and works in a slightly different way.

CCBs recommended for people who are over 55 or who are of African Caribbean origin. However, those under 55 and not of African Caribbean origin can have CCBs as a second or third medicine.

If you are pregnant, breastfeeding or planning to become pregnant, your doctor may prescribe you a CCB.

Verapamil can slow heart rate down so your doctor may prescribe you this medication if you have angina or an irregular heartbeat in addition to high blood pressure.

Examples of CCBs are Felodopine Amlodipine Diltiazem Nifedipine Lacidipine Isradipine ,Nicardipine, Lercanidipine, Nisoldipine and Verapamil. Notice how most of these medicines have names that end in “pine”.     

If you have kidney, liver or heart problems or if you are pregnant and breastfeeding your doctor may monitor you closely.

Side-effects of CCBs can include swollen ankles, headaches, dizziness, tiredness, skin rashes, ankle or foot pain, a flushed face and constipation.

It is important that you check with your doctor before taking other medicines in combination with CCBs. This is especially important when buying over-the-counter remedies as your doctor would consider your existing medicines before prescribing a new one.

 Most blood pressure medication is taken for a very long time. You should also keep taking your medication even if you think your blood pressure is now controlled as stopping it could put your health at risk

Do not take grapefruit juice with CCBs. This is because grapefruit juice can interact with CCBs (apart from amlodipine and diltiazem) and increase the amount that enters your bloodstream. This can be dangerous as it can cause your blood pressure to drop very suddenly. Orange juice and other fruit juices appear to be safe to take with CCBs.


Diuretics

Diuretics are commonly called ‘water tablets ‘because they increase the production of urine, which removes excess fluid from the bloodstream. This reduces the volume of blood in your circulatory system, and your blood pressure. There are different types of diuretic, but one commonly used to treat high blood pressure are called “thiazide” diuretics.

When there is build-up of excess fluid in your body as a result of too much salt, your blood pressure rises. Thiazide diuretics act on your kidneys so that more water and salt come out of your body through urine resulting in less excess fluid in your blood and lower your blood pressure. Diuretics can also cause the walls of your blood vessel to relax and widen and make it easier for your blood to flow through. This effect also lowers your blood pressure.

Diuretics recommended for people who are over 55 or who are of African Caribbean origin. However, those under 55 and not of African Caribbean origin can have Diuretics as a second or third medicine.

 Your doctor can prescribe you other types of diuretic, called “loop diuretics” or “potassium-sparing diuretics”, if you cannot take a thiazide diuretic, or if you are taking three blood pressure medicines. Other diuretics cause low potassium while potassium-sparing diuretics as the name implies increases potassium levels. Your doctor can prescribe you potassium-sparing diuretics to correct the low potassium levels caused by other diuretic. Your doctor may also prescribe a combination of a potassium sparing and a thiazide diuretic eg moduretic, nomoretic.

Examples of Thiazide diuretics includes: Bendroflumethiazide, Indapamide, Chlortalidone, Metolazone, Cyclopenthiazide and Xipamide.         

Examples of Loop diuretics includes:  Furosemide, Bumetanide and Torasemide.

Examples of potassium-sparing diuretics includes:  Spironolactone, Amiloride, Triamterene and Eplerenone.

If you suffer from gout, urinary ­problems, severe kidney or liver disease, or Addison’s ­disease you should not be given a thiazide diuretic. Thiazide              diuretics are also not suitable for people with diabetes because they can increase blood sugar levels.

If you have kidney, liver problems, suffer from diabetes, are elderly (i.e. over 65years) or have low potassium or sodium levels your doctor may monitor you closely.

Side-effects of diuretics can include feeling thirsty, dizzy, weak, lethargic or sick, frequent trips to the restroom to urinate, raised uric acid levels, low blood pressure when moving from lying or sitting to standing, muscle cramps, raised blood sugar levels, skin rash rarely erectile problems in men.

It is important that you check with your doctor before taking other medicines in combination with diuretic. This is especially important when buying over-the-counter remedies as your doctor would consider your existing medicines before prescribing a new one.

Most blood pressure medication is taken for a very long time. You should also keep taking your medication even if you think your blood pressure is now controlled as stopping it could put your health at risk

Diuretics can cause a reduced amount of potassium in your body. Low potassium in the body is called hypokalaemia which can be dangerous to your health. It is important that you check your potassium levels if you are taking a thiazide or loop diuretic. Intake of potassium-rich foods (e.g. fresh tomato juice, avocado) while on this medication could also reduce the risk of hypokalaemia.


Beta-blockers

Beta-blockers are no longer used as mainstream treatment for hypertension. Your doctor can sometimes prescribe you this medication if you cannot tolerate other blood pressure medicines, or if your blood pressure is not being lowered enough by other mainstream medicines. Your doctor may also prescribe you this medicine if you are pregnant.

 Beta-blockers blocks the effect of hormones called adrenaline and noradrenaline. This makes your heart beat slower and with less force, and your blood vessels open. This reduces blood pressure and improves blood flow. Beta-blockers also block your kidneys from producing a hormone called angiotensin II. Angiotensin II is a chemical in your body that enters your blood stream and causes your blood vessels to constrict and that thickens and stiffens the walls of your blood vessels and heart. It also causes a hormone in your body to make your body retain water. More fluid or sodium and water in your body together with the restricted space will cause your blood pressure to rise. Reducing the amount of angiotensin in your body allows your blood vessels to relax and widen, making it easier for blood to flow through.

You may not be prescribed beta-blockers if you suffer from asthma, because they can narrow your airways which could worsen your asthma. If you suffer from Asthma and do need to take a beta-blocker, you will need to be monitored very closely. Contact your doctor immediately if your experience breathing difficulty or you start to develop asthma when you take your beta-blocker. You may also not be prescribed beta-blockers if you have second- or third-degree heart block, worsening or unstable heart failure, or severe peripheral arterial disease.

If you have low heart rate, a type of angina known as Prinzmetal’s angina, diabetes, high levels of acid in the blood or tumour of the adrenal gland your doctor may monitor you closely while taking a beta-blocker.

Examples of beta-blockers are Metoprolol, Acebutolol, Bisoprolol, Nadolol, Oxprenolol, Timolol, Propranolol, Atenolol, Carvedilol, Labetalol, Nebivolol, Celiprolol and Pindolol. Notice how most of these medicines have names that end in “olol”

Side-effects of beta-blockers include cold hands and feet, depression, low heartbeat rate, diarrhoea and nausea, vivid dreams, lethargy, tiredness and dizziness, problems with erections in men. As beta-blockers can cause dizziness. It is important you let your doctor know immediately if you drive or operate heavy machines.

It is important that you check with your doctor before taking other medicines in combination with beta-blockers. This is especially important when buying over-the-counter remedies as your doctor would consider your existing medicines before prescribing a new one.

Most blood pressure medication is taken for a very long time. You should also keep taking your medication even if you think your blood pressure is now controlled as stopping it could put your health at risk. You should not suddenly stop taking your beta-blockers unless advised by a doctor as doing this could cause palpitation or your blood pressure to rise.

Beta-blockers can mask the warning signs of low blood sugar and is not recommended in diabetics on medications especially oral hypoglycaemic agents or insulin.

You have an increased risk of developing diabetes when you take beta-blockers and thiazide diuretics together.

Your surgeon may ask you to not take your blood pressure tablet for a while if you are going to be having anaesthetics with your surgery as anaesthetics can enhance the blood pressure lowering effect of beta-blockers and could cause your blood pressure to go lower than intended.

Alcohol enhances the blood pressure lowering effect of beta-blockers and could cause your blood pressure to go lower than intended. You should avoid alcohol if taking beta-blockers.


Non-standard medicines used in the treatment of hypertension

There are various types of medication used in the treatment of hypertension (high blood pressure). Some of these blood pressure medications are used very often because they are effective with relatively few side-effects. There are others referred to as “non-standard” blood pressure medicines that are not so commonly used. Your doctor would usually prescribe you these medication because of a special circumstance for example because you are pregnant or breastfeeding or because you are having difficulty taking other medications because of side effect or because your blood pressure remains high despite using other medications.


Alpha-blockers

Adrenaline is a hormone that causes your blood vessels to become narrow. Narrow blood vessels cause rise in blood pressure because the blood has less space to flow. Alpha-blockers stop the hormone adrenaline from narrowing your blood vessels. This allows your blood vessels to relax and widen, making it easier for blood to flow through and reduce blood pressure.

 Your doctor may prescribe alpha-blockers if you have tried other medicines without success at lowering your blood pressure. You may be prescribed alpha blockers if you are a man with an enlarged prostate or you have pheochromocytoma, which is a rare tumour of the adrenal gland that causes hypertension .

If you have a history of heart failure, kidney or liver disease, have Parkinson’s disease you may not be given an alpha blocker. Alpha blockers are also not suitable if you are pregnant, breastfeeding or planning to get pregnant. You doctor will usually not prescribe alpha blockers if you have a history of sudden drop in blood pressure when you stand or sit up (postural hypotension). Women don’t normally get alpha blockers prescribed as it can cause stress incontinence and loss of bladder control.

Examples of alpha-blockers can include Doxazosin, Terazosin, Indoramin and Prazosin.           

Side-effects of alpha blockers can include feeling weak or lethargic, tiredness, sleep disturbance, headaches, nausea, rash or itchiness of the skin, tremor, low blood pressure when moving from lying or sitting to standing, swollen legs or ankles rarely erectile problems in men.

It is important that you check with your doctor before taking other medicines in combination with alpha-blockers. This is especially important when buying over-the-counter remedies as your doctor would consider your existing medicines before prescribing a new one.

Most blood pressure medication is taken for a very long time. You should also keep taking your medication even if you think your blood pressure is now controlled as stopping it could put your health at risk.


Centrally acting drugs (central alpha antagonists)

Centrally acting drugs also known as central alpha-agonists works directly on the part of the brain that controls blood pressure. They work by blocking your brain from sending signals to the nervous system to increase heart rate and narrow blood vessels. This reduces the force of your heartbeat and your heart does not pump as hard making it easier for blood to flow through blood vessels which helps lower your blood pressure.

Your doctor may prescribe centrally acting drugs if you have tried other medicines without success at lowering your blood pressure. You may be prescribed centrally acting drug called methyldopa if you are pregnant or planning to become pregnant as it has been shown to be safe during pregnancy and breastfeeding.

Your doctor may monitor you closely while taking centrally acting drugs if you have a history of heart disease, kidney or liver disease, depression or Parkinson’s disease.

Examples of centrally acting drugs can include Methyldopa, Clonidine and Moxonidine.

Side-effects of centrally acting drugs can include feeling drowsy, tiredness, dizziness, upset stomach or nausea, dry mouth, sleep disturbance, headaches, swollen legs, depression and rarely erectile problems in men. Methyldopa can cause liver problems, a slow heartbeat, sudden drop in blood pressure when sitting up or standing up.

It is important that you check with your doctor before taking other medicines in combination with centrally acting drugs. This is especially important when buying over-the-counter remedies as your doctor would consider your existing medicines before prescribing a new one.

Most blood pressure medication is taken for a very long time. You should also keep taking your medication even if you think your blood pressure is now controlled as stopping it could put your health at risk.


Direct-acting vasodilators

Direct-acting vasodilators work by relaxing the muscles in your blood vessel walls. This allows the blood vessels to widen and makes it easier for blood to flow which lowers your blood pressure.

Your doctor may prescribe direct-acting vasodilators if you have tried other medicines without success at lowering your blood pressure. You may be prescribed a direct-acting vasodilator called hydralazine if you have heart failure.

You should not be prescribed direct-acting vasodilators if you are pregnant, breastfeeding or planning to get pregnant or if you have pheochromocytoma. You may be prescribed direct-acting vasodilators with caution if you have had heart attack or stroke recently or if you have kidney problems. You may not be prescribed direct-acting vasodilators, or you will be closely monitored if you suffer from heart disease, angina, diabetes or uraemia which is build-up of waste in your blood.

Examples of direct-acting vasodilators can include Hydralazine and Minoxidil

Side-effects of direct-acting vasodilators can include: a flushed appearance or skin rashes, upset stomach, headaches, swollen legs, rapid or irregular heartbeat, weight gain, rarely erectile problems in men and chest pain, shortness of breath or numbness. Minoxidil can cause excess body hair growth.

It is important that you check with your doctor before taking other medicines in combination with. direct-acting vasodilators. This is especially important when buying over-the-counter remedies as your doctor would consider your existing medicines before prescribing a new one.

Most blood pressure medication is taken for a very long time. You should also keep taking your medication even if you think your blood pressure is now controlled as stopping it could put your health at risk.


Aliskiren

Aliskiren is also called a “direct renin ­inhibitor”. Angiotensin is a chemical in your body that causes a rise in blood pressure. Aliskiren works by blocking the effects of a chemical called renin. Renin is involved in producing a hormone called angiotensin. The effect of this is that there is reduced amount of angiotensin in your body and lower blood pressure.

Your doctor may prescribe Aliskiren if you have tried other medicines without success at lowering your blood pressure. Your doctor would only usually prescribe you Aliskiren if you are not already taking an ACE ­inhibitor or an angiotensin receptor blocker (ARB).

You should not be prescribed Aliskiren if you are pregnant, breastfeeding or planning to get pregnant. You may not be prescribed Aliskiren if you have kidney disease, hyperkalaemia which is high potassium levels and diabetes.  If you have severe kidney disease or already having dialysis or have heart failure, your doctor may closely monitor you.

Side-effects of Aliskiren can include diarrhoea (most common side effect), inflammation of the nasal passages, skin rashes, headaches and swollen legs.

It is important that you check with your doctor before taking other medicines in combination with Aliskiren. This is especially important when buying over-the-counter remedies as your doctor would consider your existing medicines before prescribing a new one.

Most blood pressure medication is taken for a very long time. You should also keep taking your medication even if you think your blood pressure is now controlled as stopping it could put your health at risk.

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About the author

Nwasom is a pharmacy graduate and a pharmacist currently practising in the United Kingdom. I have great experience communicating with patients and their family as gained through working as a pharmacist in both the hospital and community pharmacy sector. I love writing so it was a natural thing to try and pass medical and health information on through writing.