My approach to BP after hearing dogma at multiple institutions:
AAA-Angiotensin, Alpha (clonidine, doxazosin, minoxidil), Afterload (Imdur/Hydral)
Beta Blocker (Coreg, Labetalol)
Calcium Channel (Amlodipine, Nifedipine)
Diuretics (Hctz, chlorthalidone, indapamide step up, then spironolactone class, then lasix for dialysis patients for volume overload)
That helps list all the medications AND it serves as what to start first line.
Now the approach:
1.) SSS: Smoking, Salt, Sleep apnea. Salt intake may seem trivial but a deliberate diet can actually make a sizable difference.
2.) I look at HF/DM vs not. HF/DM get ACE as a first line. Those without it get CCB, the most convenient one. I also check a Pr/Cr to see if a Angiotensin drug can be justified.
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3.) For systolic >20 points above my target (120–130) or diastolic above 10 (80-90) I prescribe two medications. I also heavily prescribe to the multiple medication strategy as opposed to spamming dose increases on a single medication strategy on follow ups. If we are making changes, let’s actually make meaningful ones instead of trying to make it look like we are doing something for namesake. It may create some turbulence initially but at least you can settle on a regimen faster this way. I understand it sounds scientific to say that we can change one variable/med at a time but the irony is that the majority of the scientific evidence has shown that increase past half the dose gives more side effects and less control. Fill everyone’s glass before you fill each to the brim! To account for patient’s hesitation to take multiple pills, diovan and other mixed pills are my friend.
Double check and verify compliance and test patients on what they are taking between visits.
4.) Listen to patients when they mention side effects but don’t let it limit your first line therapies. Thiazides don’t cause constant urination if the patients are taking it daily. ARBs should not cause chronic cough. Challenge intolerances when able. Common legit intolerances are electrolyte issues in old people on thiazides, really bad lifestyle altering leg swelling on amlodipine, weird atopic things like enteropathy/cough with angiotensin drugs, and so on.
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Double check and verify compliance and test patients on what they are taking between visits.
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5.) Once I get them on two medications and they are still uncontrolled it depends how much. If it’s a lot I’ll go to step 6. If it’s a little I’ll just increase the dose as dose increases provide only little improvement.
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Double check and verify compliance and test patients on what they are taking between visits.
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6.) If that doesn’t work, I’ll add spironolactone especially if there’s a diuretic on board and test for stuff if needed. If needed I’ll manage the potassium medically as opposed to avoiding spironolactone. All these meds cancel each other out diuretic vs. Spiro.
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Double check and verify compliance and test patients on what they are taking between visits.
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7.) If the patient is on the ALL-HAT meds (Angiotensin, CCB, Thiazides) and MRAs and they are uncontrolled that’s when I play the class switching game. Whether it’s HCTZ>Chlorthalidone>Indapamide, Amlodipine to Nifedipine XL 60 BID, or Losartan> Losartan BID >Valsartan>Olmesartan or Coreg BID to Labetalol TID,
I start doing stuff like that.
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Double check and verify compliance and test patients on what they are taking between visits.
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8.) After that, I have to think outside the box and do what will do the least harm. Pick a poison from each bag. Don’t double pick from the same bag.
Poison Bag A: Beta-Blockers, Clonidine.
Poison Bag B: Hydral/Nitrate, Doxazosin
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Double check and verify compliance and test patients on what they are taking between visits.
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8.) If all this doesn’t work, then I will usually ask for Cardiology if there is some other cardiac issue or Nephrology if there isn’t. Lasix can help if volume overload is an issue.
They may do a few other adjustments but that’s really it.
