Tuesday, October 16, 2007

Which Drug to Use to Reduce High Blood Pressure

Regardless of your age, much of the time high blood pressure can be controlled with just one drug. The National Institutes of Health’s National Heart, Lung and Blood Institute recommends beginning treatment with a mild water pill (diuretic) at a low dose. The safest and best studied of the diuretics is  hydrochlorothiazide (ESIDRIX, HYDRODIURIL, MICROZIDE). The starting dose should be low: 12.5 to 25 milligrams per day or even every other day. Confirming the advice we have been giving since 1988 is a large definitive study (named ALLHAT) involving more than 33,000 patients aged 55 or older that found “compelling evidence that thiazide diuretics (such as hydrochlorothiazide or chlorthalidone) should be the initial drug of choice for patients with hypertension.” Thus, the widespread prescribing practice—spurred on by massive advertising—of starting people with newly diagnosed hypertension with calcium channel blockers (such as Norvasc, Cardizem, or Procardia), ACE inhibitors (such as Zestril, Accupril, or Vasotec), or other drugs that are not thiazides lacks any scientific rationale.

For older adults, in general, the rule for treating high blood pressure, as with so many other drug treatments, is “start low and go slow.” According to experts in prescribing for older adults, for mild hypertension (or heart failure) start with half the standard starting dose and increase gradually.

If a second drug is needed the National Heart, Lung, and Blood Institute recommends  beta blockers, although they are not as effective in older adults as they are in younger adults. Because of this, beta-blockers should never be used as the first drug in treating high blood pressure in older adults. ACE inhibitors are also effective drugs to use as a second agent. It is rarely necessary to take more than two drugs to treat high blood pressure. If you are taking more than two, a reassessment is indicated.

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