Medications for Treating HypertensionDoctors once hesitated to prescribe medication for patients with blood pressure below 159/99 mm Hg, which was once deemed “mild hypertension,” because they didn’t consider that level dangerous. Many doctors worried that the drugs’ potential side effects might outweigh their benefits. Both of these perceptions turned out to be false. Research has firmly established the value of treating stage 1 hypertension (140/90–159/99 mm Hg) with drugs, if necessary. For those with diabetes or kidney disease, medications may be necessary at pressures as low as 130/80. And today, blood pressure can be controlled with lower doses of medications, meaning there is less chance of side effects. Doctors can choose from an abundant selection of antihypertensive medications, including many preparations that combine one or more drugs. Many newer antihypertensive drugs have a slightly different chemical structure from older drugs, but produce nearly identical effects in the body. Others act in entirely different ways. Doctors can tailor treatment to the individual patient and can often prescribe a drug that controls blood pressure, produces few or no side effects, and, hopefully, protects against complications. Most important, it’s often possible to use a single medication to treat both the hypertension and accompanying medical problems, like congestive heart failure. The JNC recommends starting any antihypertensive drug at the lowest possible dose and gradually increasing it until blood pressure sinks to a normal level. If the drug doesn’t lower pressure or if it causes troublesome side effects, it should be replaced with a different medication. The usual course of treatment for stage 1 hypertension is to begin with one drug and add a second if your blood pressure does not decrease to desired levels (usually less than 140/90 mm Hg; less than 130/80 mm Hg for those with diabetes or chronic kidney disease). The treatment for stage 2 hypertension often begins with a two-drug combination. A third may be added if your blood pressure doesn’t drop to an acceptable level. With all stages of hypertension, and even prehypertension, lifestyle changes are also an important component of treatment. The JNC found that blood pressure can be adequately controlled in most people with hypertension, but many individuals will need two or more medications to get their blood pressure in check. Poor blood pressure control can result if the doctor doesn’t encourage lifestyle changes, prescribe adequate doses of medications, or add additional medications as needed. Classes of hypertension drugsDoctors can choose from several classes of antihypertensive drugs: diuretics, anti-adrenergics, direct-acting vasodilators, calcium-channel blockers, angiotensin-converting–enzyme (ACE) inhibitors, and angiotensin II receptor blockers. In addition, researchers are testing two potent new classes, endothelin receptor antagonists and vasopeptidase inhibitors. With so many choices available, which medication should you and your doctor choose? The JNC recommends that most people with hypertension start with diuretics, but many experts disagree with this advice (see “Diuretics as a first choice?”). In light of the controversy, it’s wise to talk to your doctor about which medications are best for you. Fast fact Fast fact In the United States, 66% of adults with hypertension don’t have their blood pressure under control. |
Diuretics Diuretics, commonly called “water pills,” are the oldest and least expensive class of drugs used to treat hypertension. They help the kidneys eliminate sodium and water from the body. This process decreases blood volume, so your heart has less to pump with each beat, which in turn lowers blood pressure. Loop diuretics, which act on the part of the kidney tubules called the loop of Henle, block sodium and chloride from being reabsorbed from the tubule into the bloodstream. Thiazide diuretics act on another portion of the kidney tubules to stop sodium from reentering circulation. One drawback of diuretics is they deplete potassium, so if you take these drugs you may need potassium supplements. Doctors sometimes prescribe another type of diuretic, called potassium-sparing diuretics, to counteract potassium depletion. However, these drugs can cause dangerously high levels of potassium in some patients. Diuretics are especially effective for salt-sensitive patients with hypertension and older patients with isolated systolic hypertension. Aside from hypertension, diuretics are often prescribed for fluid retention (edema) caused by heart failure, kidney disorders, liver disease, or premenstrual bloating. According to the May 2003 JNC report, diuretics are very effective and underused. The JNC recommends that thiazide diuretics be the initial drug used for most people with hypertension, and suggests that these medications be part of treatment for most individuals taking multiple medications to control their blood pressure. But this recommendation is somewhat controversial (see “Diuretics as a first choice?”). Common side effects of these drugs include frequent urination, lightheadedness, fatigue, diarrhea or constipation, and muscle cramps. Men may occasionally experience erectile dysfunction. Diuretics can cause gout, a painful form of arthritis caused by the buildup of uric acid in the body, because they elevate blood levels of this substance. Diuretics as a first choice?Designing an effective medication program for hypertension is like fitting together the pieces of a jigsaw puzzle. Matching the benefits and side effects of the dozens of available drugs to a particular person’s risk factors, health conditions, and lifestyle considerations is often a trial-and-error process. What may work well for your neighbor or cousin may not be right for you. It may take some time to find a medication that offers you the best blood pressure control with the fewest side effects. Back in the 1980s, doctors had to rely exclusively on a class of drugs known as diuretics, or “water pills.” But then a host of newer heart medications came on the scene — many of which reduced blood pressure while offering other cardiovascular benefits. Increasingly, these more expensive alternatives overtook diuretics as the first choice for treating hypertension. Seeking to differentiate among the new categories of hypertension drugs, researchers designed a study to determine the relative effectiveness of some newer medications in preventing heart disease and stroke against similar data on the old standby choice, diuretics. The resulting Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) examined blood pressure control and cardiovascular events in more than 33,000 men and women, age 55 or older, with mild to moderate hypertension. For five years, the participants took one of three drugs: chlorthalidone (a diuretic), amlodipine (a calcium-channel blocker), or lisinopril (an ACE inhibitor). To many people’s surprise, the diuretic seemed to perform as well as or slightly better than the newer drugs in controlling blood pressure and preventing complications such as stroke and heart failure. These results and the low cost of diuretics prompted the JNC to recommend thiazide diuretics as the first line of treatment for most people with hypertension. For people with certain health problems, including diabetes, kidney disease, or heart failure, other medications may be a better first choice. While it’s heartening to know that one of the most cost-effective hypertension medications is also one of the best, not everyone is willing to jump wholeheartedly on the diuretic bandwagon. First of all, diuretics can raise blood sugar and lower potassium levels. Critics also point out that because ALLHAT was conceived in the 1990s, it didn’t evaluate beta blockers or some newer medications that are commonly used to treat hypertension today, such as angiotensin II receptor blockers. They also cite certain flaws in the study design that may have skewed the results in favor of diuretics. On such factor was that 90% of the participants were already on some type of blood pressure medication at the start of the trial and did not undergo a “wash-out” period to get the old medications out of their systems before beginning the drug regimen that the study prescribed. In addition, most of the subjects were elderly (average age 67) and over a third were African Americans; these two groups are known to respond more favorably to diuretics than ACE inhibitors. Finally, the drug combinations used when two or more drugs were needed did not always coincide with the drug selections made in clinical practice. Where does this controversy leave patients? Dr. Randall Zusman, director of the division of hypertension and vascular medicine at Massachusetts General Hospital, recommends that you and your doctor choose a medication based on your individual health conditions and lifestyle considerations, instead of using a one-size-fits-all approach. |
Diuretics | Class | Generic name | Brand name | Side effects | Thiazide diuretics | chlorothiazide | Diuril | Weakness, confusion, potassium depletion, gout, fatigue, thirst, frequent urination, lightheadedness, muscle cramps, diarrhea or constipation, increased sensitivity to sunlight, allergic reaction in people allergic to sulfa drugs, impotence. | chlorthalidone | Hygroton | hydrochlorothiazide | Esidrix, HydroDIURIL, Microzide | indapamide | Lozol | metolazone | Mykrox, Zaroxolyn | polythiazide | Renese | Loop diuretics | bumetanide | Bumex | Weakness, confusion, potassium depletion, gout, fatigue, thirst, diarrhea or constipation, increased sensitivity to sunlight, allergic reaction in people allergic to sulfa drugs, impotence. | ethacrynic acid | Edecrin | furosemide | Lasix | torsemide | Demadex | Potassium-sparing diuretics/ aldosterone receptor blockers* | amiloride | Midamor | Excessive potassium levels, especially in patients with kidney disease; breast enlargement and erectile dysfunction in men; menstrual irregularities in women. | eplerenone | Inspra | Headache, dizziness, diarrhea, fatigue, upset stomach, and breast enlargement or tenderness. | spironolactone | Aldactone | Excessive potassium levels, especially in patients with kidney disease; breast enlargement and erectile dysfunction in men; menstrual irregularities in women. | triamterene | Dyrenium | * Note: These potassium-sparing diuretics also directly or indirectly block aldosterone, a hormone that raises blood pressure by causing the kidneys to conserve sodium and water. As a result, these four medications are sometimes also known as aldosterone blockers. Amiloride (Midamor), spironolactone (Aldactone), and triamterene (Dyrenium) affect other hormones as well and thus carry some unwanted side effects such as breast enlargement and impotence in men and menstrual irregularities in women. Eplerenone (Inspra) is the newest of these medications and the only one that affects only aldosterone and not other hormones. |
Anti-adrenergicsAnti-adrenergics lower blood pressure by limiting the action of the hormones epinephrine and norepinephrine, thereby relaxing the blood vessels and reducing the speed and force of the heart’s contractions. They include peripheral nerve acting agents, peripheral adrenergic receptor blockers, and centrally acting agents. Anti-adrenergic Drugs | Class | Generic name | Brand name | Side effects | Beta blockers (cardioselective) | acebutolol | Sectral | Wheezing, dizziness, depression, impotence, fatigue, insomnia, decreased HDL cholesterol levels, lower exercise tolerance. Can worsen peripheral vascular disease and heart failure. Abrupt withdrawal may trigger angina or a heart attack in patients with heart disease. | atenolol | Tenormin | betaxolol | Kerlone | bisoprolol | Zebeta | metoprolol | Lopressor | metoprolol extended release | Toprol-XL | Beta blockers (nonselective) | nadolol | Corgard | Wheezing, dizziness, depression, impotence, fatigue, insomnia, decreased HDL cholesterol levels, lower exercise tolerance. Can worsen peripheral vascular disease and heart failure. Abrupt withdrawal may trigger angina or a heart attack in patients with heart disease. | penbutolol | Levatol | pindolol | Visken | propranolol | Inderal, Inderal LA | sotalol | Betapace | timolol | Blocadren | Alpha-1 blockers | doxazosin | Cardura | A drop in blood pressure upon standing up, fainting, weakness, heart palpitations, headache, nasal congestion, dry mouth. | prazosin | Minipress | terazosin | Hytrin | Centrally acting agents | clonidine | Catapres, Catapres-TTS | A drop in blood pressure upon standing up, drowsiness, sedation, dry mouth, fatigue, erectile dysfunction, depression, dizziness. Catapres-TTS (a patch) may cause a rash. | guanabenz | Wytensin | guanfacine | Tenex | methyldopa | Aldomet | Alpha and beta acting | carvedilol | Coreg | Wheezing, depression, insomnia, diarrhea, lightheadedness, dizziness, unusual tiredness or weakness, drying of the eyes, erectile dysfunction, headache, dry mouth, nasal congestion, decreased HDL cholesterol levels, lower exercise tolerance, a drop in blood pressure upon standing up, fainting, heart palpitations. Can worsen peripheral vascular disease and heart failure. Abrupt withdrawal may trigger angina or a heart attack in patients with heart disease. | labetalol | Normodyne, Trandate | Peripheral nerve acting agents | guanethidine | Ismelin | A drop in blood pressure upon standing up, depression, nasal stuffiness, nightmares. | reserpine | Serpalan |
Peripheral nerve acting agents. These anti-adrenergics (now used far less often because of frequent side effects) deplete the autonomic nerves of norepinephrine, a substance that causes vessels to contract and raises blood pressure. Such drugs are usually prescribed along with other antihypertensives since they are more effective this way. Reserpine (Serpalan) can cause depression, nightmares, nasal stuffiness, and indigestion, while guanethidine (Ismelin) is more apt to bring on a drop in blood pressure upon standing up (orthostatic hypotension) and to slow the heart rate. Peripheral adrenergic receptor blockers. These drugs work by preventing neurotransmitters from attaching to cells and stimulating the heart and blood vessels. They are divided into two major groups: beta blockers and alpha blockers (see “Receptor blockers: Fooling the body”). Beta blockers, which have been used since the 1960s, lock on to cell structures called beta receptors — the same receptors that certain neurotransmitters (primarily epinephrine) normally attach themselves to in order to stimulate the heart. Thus, by preventing the neurotransmitters from activating heart cells, beta blockers cause the heart rate to slow and blood pressure to fall. Beta blockers come in two varieties: cardioselective and nonselective. Cardioselective beta blockers attach primarily to beta-1 receptors in the heart. Nonselective beta blockers attach to beta-1 receptors and beta-2 receptors, which are found in the lungs, blood vessels, and other tissues. Either type of beta blocker can worsen asthma or other chronic lung disorders, but the nonselective agents are potentially more dangerous for people with respiratory problems. Beta blockers can also worsen heart failure in some patients, while improving it in others. They can mask the warning signs of hypoglycemia (low blood sugar) in patients with diabetes. The most common side effects of beta blockers are fatigue, depression, erectile dysfunction, shortness of breath, insomnia, and reduced tolerance for exercise. Alpha blockers are similar in action to beta blockers, but they work on alpha receptors — the sites where neurotransmitters that cause vessel constriction (primarily norepinephrine) attach themselves. Drugs called alpha-1 blockers block alpha receptors in the heart and blood vessels. They may be especially useful for hypertensive patients with high cholesterol. In addition to reducing blood pressure, alpha-1 blockers also reduce “bad” LDL cholesterol levels and increase “good” HDL cholesterol. They may improve insulin sensitivity in patients with glucose intolerance and hyperglycemia (high blood sugar). They are also prescribed for men with benign prostatic hyperplasia, a noncancerous enlargement of the prostate gland, because these drugs relax smooth muscles surrounding the prostate, relieving the constriction of the urethra and easing urine flow. Side effects of alpha blockers include orthostatic hypotension, heart palpitations, dizziness, nasal congestion, headaches, and dry mouth. These drugs can also cause erectile dysfunction, although not as frequently as some other blood pressure medications. Some patients require both alpha and beta blockers to control their blood pressure. The drugs labetalol (Normodyne) and carvedilol (Coreg) have properties of both. Centrally acting agents. These agents block the neurotransmitters that activate the sympathetic nervous system to increase blood pressure. They include clonidine (Catapres), guanabenz (Wytensin), guanfacine (Tenex), and methyldopa (Aldomet). Like peripheral nerve acting agents, they are generally used in combination with other blood pressure medicines. Common side effects include abnormally low blood pressure when standing up, dry mouth, depression, erectile dysfunction, and sedation. Direct-acting vasodilatorsDirect-acting vasodilators relax the arterial blood vessels. They act quickly and are often used in emergencies. However, they can cause fluid retention and tachycardia (fast heart rate), so doctors usually prescribe them in combination with another blood pressure medication that slows heart rate, such as a cardioselective beta blocker. Hydralazine and minoxidil, the direct-acting vasodilators most commonly used to treat hypertension, can cause headaches, weakness, flushing, and nausea. In addition, minoxidil can cause hair growth, fluid retention, and hyperglycemia (increased blood sugar). Calcium-channel blockersCalcium-channel blockers slow the movement of calcium into the smooth-muscle cells of the heart and blood vessels. This reduces the strength of heart muscle contractions and dilation of blood vessels, lowering blood pressure. Because calcium-channel blockers also slow nerve impulses in the heart, they are often prescribed for arrhythmias (irregular heartbeat). Common side effects of calcium-channel blockers are headache, edema, heartburn, bradycardia (slow heart rate), and constipation. ACE inhibitors This class of drugs, introduced in 1981, has proved widely effective in treating hypertension. These agents prevent your kidneys from retaining sodium and water by deactivating angiotensin-converting enzyme (ACE), which converts inactive angiotensin I to the active angiotensin II. Angiotensin II raises blood pressure by triggering sodium and water retention and constricting the arteries. ACE inhibitors reduce blood pressure in most patients and produce fewer side effects than many other antihypertensive drugs. In addition, ACE inhibitors protect the kidneys of people with diabetes and kidney dysfunction and the hearts of people with congestive heart failure. The most common side effects of these medications are a reduced sense of taste and a dry cough. Rarely, a patient can have difficulty breathing because of a swelling of the lips, tongue, and throat. ACE inhibitors can also cause potassium retention; therefore, people with poor kidney function must use them cautiously. Because these drugs can cause spontaneous abortion, women who are pregnant or trying to get pregnant should not take them. Angiotensin II receptor blockersThis class of medication, approved for treating hypertension since 1995, blocks angiotensin II from constricting the blood vessels and stimulating salt and water retention. Because angiotensin receptor blockers are highly effective and well tolerated by most people who take them, these medications have become quite popular. They don’t produce any of the traditional side effects of other antihypertensive medications, and they’re less likely to cause a cough like ACE inhibitors do. In addition, like ACE inhibitors, they benefit patients with diabetes, congestive heart failure, or both. Direct-acting vasodilators | Generic name | Brand name | Side effects | hydralazine | Apresoline | Headaches, palpitations, weakness, flushing, nausea. Minoxidil may cause hair growth, fluid retention, and increased blood sugar. | minoxidil | Loniten | Calcium-channel blockers | amlodipine | Norvasc | Headache, dizziness, edema, and heartburn. Nifedipine can cause palpitations. Diltiazem and verapamil can cause constipation and a slowed heartbeat. | diltiazem | Cardizem CD, Cardizem SR, Dilacor XR, Tiazac | felodipine | Plendil | isradipine | DynaCirc | nicardipine | Cardene, Cardene SR | nifedipine | Adalat CC, Procardia XL | nimodipine | Nimotop | nisoldipine | Sular | verapamil | Calan, Calan SR, Isoptin, Isoptin SR, Verelan PM | Ace inhibitors | benazepril | Lotensin | Cough, rash, fluid retention, high potassium levels, and loss of taste. May cause low blood pressure and fainting. Can worsen kidney impairment if narrowed arteries feed both kidneys. May cause fetal abnormalities. | captopril | Capoten | enalapril | Vasotec | fosinopril | Monopril | lisinopril | Prinivil, Zestril | moexipril | Univasc | perindopril | Aceon | quinapril | Accupril | ramipril | Altace | trandolapril | Mavik | Angiotensin II receptor blockers | candesartan | Atacand | Muscle cramps, dizziness. | eprosartan | Teveten | irbesartan | Avapro | losartan | Cozaar | olmesartan | Benicar | telmisartan | Micardis | valsartan | Diovan |
Receptor blockers: Fooling the bodyThe discovery of the “lock-and-key” system of cell communication opened the door to a new world of drug research. The search began with a simple question: Why do some cells react to particular chemicals, but not others? The answer is both maddeningly complex and blessedly simple. Chemicals circulating through the blood, such as hormones and neurotransmitters, stimulate cells. At any given moment, a cell may come in contact with hundreds of different chemicals, so it must be selective about which ones it responds to. To do this, cells have special structures on their outer surfaces called receptors. A receptor operates much like a car’s ignition switch. Only a chemical with the right molecular configuration (the key) will fit the receptor (the lock) and start up biological activity inside the cell. Researchers have used their knowledge of this system to formulate drugs that prevent cells from responding to certain substances. Beta blockers, which are used to treat hypertension, are a prime example. At times of stress and during exercise, your nerve cells release the neurotransmitters epinephrine and norepinephrine. When epinephrine attaches to beta receptors on cells in your heart, the heart cells become activated, increasing your heart rate and the strength of your heart’s contractions. This raises your blood pressure. But beta blockers attach to the same receptors, because their structure has been carefully designed to fit neatly into the same “lock.” With this spot filled, epinephrine and norepinephrine are unable to connect to the receptor, thus breaking the chain of chemical communication that would otherwise stimulate the heart and spark an increase in blood pressure. |
Drug combinationsOften, antihypertensive medications are combined into one tablet. This combination allows you to take fewer pills each day and may make it easier for you to stick with your treatment. Some of the most commonly used combination medications are listed in the table below. For side effects, see the listings for the individual drugs in the previous tables. Combination antihypertensive drugs | Class | Generic name | Brand name | Potassium-sparing and thiazide diuretics | amiloride + hydrochlorothiazide | Moduretic | spironolactone + hydrochlorothiazide | Aldactazide, Spironazide, Spirozide | triamterene + hydrochlorothiazide | Dyazide, Maxzide | Alpha blocker and diuretic | prazosin + polythiazide | Minizide | Beta blocker and diuretic | atenolol + chlorthalidone | Tenoretic | bisoprolol + hydrochlorothiazide | Ziac | metoprolol + hydrochlorothiazide | Lopressor HCT | nadolol + bendroflumethiazide | Corzide | propranolol + hydrochlorothiazide | Inderide, Inderide LA | timolol + hydrochlorothiazide | Timolide | ACE inhibitor and diuretic | benazepril + hydrochlorothiazide | Lotensin HCT | captopril + hydrochlorothiazide | Capozide | enalapril + hydrochlorothiazide | Vaseretic | fosinopril + hydrochlorothiazide | Monopril-HCT | lisinopril + hydrochlorothiazide | Prinzide, Zestoretic | moexipril + hydrochlorothiazide | Uniretic | quinapril + hydrochlorothiazide | Accuretic | Angiotensin receptor blocker and diuretic | candesartan + hydrochlorothiazide | Atacand HCT | eprosartan + hydrochlorothiazide | Teveten HCT | irbesartan + hydrochlorothiazide | Avalide | losartan + hydrochlorothiazide | Hyzaar | telmisartan + hydrochlorothiazide | Micardis HCT | valsartan + hydrochlorothiazide | Diovan HCT | Calcium-channel blocker and ACE inhibitor | amlodipine + benazepril | Lotrel | diltiazem + enalapril | Teczem | felodipine + enalapril | Lexxel | verapamil + trandolapril | Tarka | Other combinations | methyldopa + hydrochlorothiazide | Aldoril | reserpine + chlorothiazide | Diupres | reserpine + chlorothiazide | Hydropres |
The right drug for the right personIf you can’t control your blood pressure by adopting healthier habits — such as limiting salt, increasing exercise, and quitting smoking — and you are free of other diseases, the JNC recommends thiazide diuretics as the first medications to try. The committee recommends these drugs because they have been tested more extensively in clinical trials than any other classes of antihypertensives and have been shown to be highly successful in controlling blood pressure. Diuretics can also improve the effectiveness of other blood pressure drugs when used in combination with them. Further, diuretics have the advantage of being among the least expensive of the various types of hypertension medications. But the committee has been criticized for favoring diuretics over other agents (see “Diuretics as a first choice?”), and physicians often use other drugs because hypertension is rarely the only disease present. For instance, diabetes and heart disease often accompany hypertension, and newer drugs, such as ACE inhibitors or angiotensin receptor blockers, perform double duty by helping to treat these conditions while lowering blood pressure. In any case, the best regimen is one that’s tailored to your needs and is based on your medical history, any coexisting diseases, your preferences about how and when to take medications, and your concerns about side effects. These general recommendations may also be helpful. Tips to help you remember to take your blood pressure medicineTake your medicine after you brush your teeth. Keep it with your toothpaste as a reminder. Put “sticky” notes in visible places to remind yourself. Use a weekly pillbox to store your medicines so you can see at a glance whether you’ve taken the current day’s dose. Keep your medicine on the nightstand next to your bed. Ask a friend or relative to call your telephone answering machine to remind you to take your medicine; then don’t erase the message. Establish a buddy system with a friend who also takes a medication each day. |
African AmericansDeveloping healthy habits is particularly important among African Americans because they have higher rates of smoking, obesity, diabetes, and salt sensitivity. They are also more likely to incur complications such as stroke or kidney damage as a result of unchecked hypertension. Diuretics work especially well in this population because of their effectiveness in treating hypertension in patients who are salt sensitive. On the other hand, ACE inhibitors seem to be less effective at low doses when prescribed as a single medication. Ultimately, many African Americans have such severe hypertension that two or more drugs are needed to bring their blood pressure under control. Older peopleFor older people, the JNC recommends thiazide diuretics, either alone or in combination with beta blockers, but calcium-channel blockers are also often used. Older people should not use medications that are prone to cause orthostatic hypotension (a sudden drop in blood pressure upon standing up), such as anti-adrenergics and alpha blockers, because these drugs can lead to fainting and falls, a common cause of hip fractures. Older adults should also avoid combination medications that contain alpha blockers, such as labetalol. ACE inhibitors and angiotensin receptor blockers may also be appropriate in the elderly because of the high incidence of diabetes. People with coronary artery diseasePeople with hypertension complicated by angina often benefit from beta blockers and calcium-channel blockers. The JNC recommends beta blockers for those who have had heart attacks because these medications reduce the risk of having another one. People with congestive heart failureBecause ACE inhibitors help prevent the progression of heart failure, the JNC recommends these drugs — either alone or in combination with a diuretic — for people who have congestive heart failure and high blood pressure. Beta blockers and drugs that block angiotensin receptors may also be helpful. People with left ventricular hypertrophyThe JNC found that all antihypertensive drugs except direct-acting vasodilators (hydralazine and minoxidil) reduce left ventricle wall thickness. ACE inhibitors, however, are generally considered to be the most effective. Weight loss and salt restriction are also effective strategies for patients with this condition. People with kidney diseaseAll types of antihypertensive drugs are effective in patients with kidney disease, and in many cases more than one type of medication will be needed. People with kidney disease or diabetes respond favorably to ACE inhibitors because these drugs can slow the rate of the progression of kidney failure. But ACE inhibitors can promote a dangerous buildup of potassium, especially when taken with nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and many prescription painkillers. Consequently, potassium levels and kidney function tests must be closely monitored. People with chronic kidney failure often develop hypertension because they retain too much sodium and water. Frequently, loop diuretics are required to help control hypertension in these patients, but the JNC cautions that potassium-sparing diuretics can be dangerous. People with diabetes ACE inhibitors or angiotensin II receptor blockers are the preferred choices for patients with diabetes because these drugs slow the rate of kidney disease. Several antihypertensive drugs can be dangerous for diabetics. For example, thiazide diuretics may elevate blood sugar levels, and beta blockers can mask the symptoms of hypoglycemia. People with high cholesterolIf you need medication to control high cholesterol, alpha-1 blockers may slightly reduce your total cholesterol and raise your levels of protective HDL. The harmful effect of some hypertension medications on blood lipids has raised concern among doctors about prescribing these drugs to people with high cholesterol. Beta blockers can increase triglyceride levels and reduce beneficial HDL. In high doses, thiazide and loop diuretics can raise overall cholesterol levels, “bad” LDL cholesterol, and triglycerides. Calcium-channel blockers, ACE inhibitors, and angiotensin receptor blockers do not affect blood lipids. People with respiratory diseaseBecause beta blockers can aggravate symptoms of chronic bronchitis, emphysema, and asthma, they aren’t recommended as initial therapy for anyone with these conditions. Most other antihypertensive agents can be used safely for patients with respiratory ailments. Because many over-the-counter asthma preparations and cold remedies contain vasoconstrictors, which can raise both heart rate and blood pressure, you should consult your doctor before taking these medications. People with goutHigh blood levels of uric acid can trigger gout, a painful joint disorder. Diuretics can increase uric acid levels, making gout attacks more likely. For this reason, diuretics aren’t recommended for people with gout unless they take other measures to control their uric acid levels.
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