Medication is a cornerstone of treatment for high blood pressure, or hypertension. Your doctor has many classes of antihypertensive drugs to choose from, and each class has a long list of possible pills that may help you reduce your blood pressure. The regimen that’s right for you depends on your particular health.
“It’s based on the individual’s baseline risks and presence of chronic disease. Are you a man or woman? Are you pregnant? Do you have chronic kidney disease? Are you diabetic? Have you had a heart attack? Are you Black, with a high risk for cardiac events? How old are you? In a sense, it’s algorithmic; once you put in all the factors, it leads us to drugs that are right for you,” explains Dr. Chippy Ajithan, a cardiologist based in Sarasota, Florida.
While there are hundreds of medication choices, treatment is typically guided by evidence-based recommendations, such as those from the American College of Cardiology/American Heart Association or the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure.
[Read: The Best Diets for Your Heart]
First Lines of Defense
When you’re initially diagnosed with high blood pressure — typically defined as a measurement at or above 130/80 millimeters of mercury (mmHg) — your doctor will consider if you have any underlying conditions.
If you’re generally healthy, your doctor might prescribe powerful, proven medications such as:
— Thiazide diuretics (“water pills”), such as hydrochlorothiazide (Microzide) and chlorothiazide (Diuril). Thiazide diuretics help relieve pressure on your blood vessels by prompting the kidneys to remove excess fluid and salt from your body.
— Calcium channel blockers, such as amlodipine (Norvasc) or diltiazem (Cardizem). These drugs block calcium from getting into cells in the heart and blood vessels, which helps your heart beat less forcefully.
— Angiotensin-converting enzyme inhibitors, such as lisinopril (Prinivil) or captopril (Capoten). ACE inhibitors reduce your body’s production of angiotensin, a hormone that helps your blood vessels constrict.
— Angiotensin-receptor blockers, such as losartan (Cozaar) or valsartan (Diovan). ARBs help block angiotensin and relax the blood vessels.
“These classes of medications have been shown to decrease further progression of kidney disease, decrease mortality and reduce your risk of stroke, heart attack and heart failure,” Ajithan says.
If a medication isn’t doing enough to reduce your blood pressure after one month, your doctor may increase the dose or add another drug to your regimen.
Medications in this arsenal include:
— Beta blockers, such as atenolol (Tenormin) or metoprolol (Lopressor). Beta blockers help slow your heart rate by reducing the amount of stress hormones (such as adrenaline) in the body. The drugs might be used in people with an abnormal heartbeat or a history of heart attack. “Beta blockers are good at helping the heart remodel. They’re good for people with heart failure with reduced ejection fraction and for people with coronary artery disease,” says Dr. Megan Kamath, a cardiologist with UCLA Health.
— Vasodilators, such as hydralazine (Apresoline) or minoxidil (Loniten). Vasodilators relax the muscles in the blood vessel walls, enabling blood to flow more easily.
— Loop diuretics, such as bumetanide (Bumex) or ethacrynic acid (Edecrin). These diuretics act on a different part of the kidney than thiazide diuretics. “Loop diuretics are secondary players,” Ajithan says. “They’re for people who have congestive heart failure, alcoholic liver cirrhosis or advanced kidney failure, but they may deplete potassium levels. So you may need a potassium-sparing diuretic. It’s been shown to be a great additive medication for resistant hypertension.”
— Centrally acting agents, such as clonidine (Catapres, Kapvay), guanfacine (Intuniv) or methyldopa. These medications help slow your heart rate and keep your blood vessels from constricting by interfering with signals from the brain. “Methyldopa is what we give to pregnant women with high blood pressure because ACE inhibitors and ARBs have been shown to be toxic to the fetus,” Ajithan says.
[Read: Foods for Hypertension.]
Medication Side Effects
While medications can dramatically lower your blood pressure, they can also lead to side effects.
“If a patient is prone to swollen ankles, calcium channel blockers can make that worse, by dilating the blood vessels so they allow more blood to flow through them. When you do that, it allows extra blood to flow to the legs, and it has trouble getting back up to the heart,” points out Dr. Matt Muldoon, a hypertension specialist with the University of Pittsburgh Medical Center.
Other side effects of medications for hypertension:
— ACE inhibitors may cause a cough, an allergic reaction or high potassium levels.
— Diuretics may cause impotence, gout or high blood sugar.
— ARBs may cause dizziness.
— Beta blockers may cause insomnia, cold hands and feet, fatigue or depression.
— Some centrally acting agents may cause dry mouth or make you constipated or drowsy.
— Vasodilators may cause headaches or heart palpitations.
It’s not uncommon to wind up with a regimen that includes several antihypertensive drugs.
“If you have severe hypertension and your initial blood pressure is 180/110, we know from the get-go that it will take at least two and maybe three or four medications. I’ve seen it get out of hand,” Muldoon says. “I had a patient who was taking six medications.”
Taking a lot of antihypertensives can lead to:
— Increased side effects.
— Confusion about your medication regimen.
— Medication noncompliance.
If you feel you’re taking too many medications for hypertension, you can talk to your doctor about trying to reduce the pill count. It takes trial and error (and your doctor’s supervision) to see if a drug can be eliminated.
“It’s labor-intensive and done with the patient measuring their blood pressure regularly. You take one medication away and get an average blood pressure reading over two to four weeks,” Muldoon says. “Then we compare that average to their blood pressure previously, when still on the medication.”
Still No Relief?
Despite the available medications for hypertension, 75% of U.S. adults diagnosed with high blood pressure don’t have it under control.
“It’s a reflection of the fact that many other factors play a role in treating high blood pressure: weight loss for overweight patients; eating a healthy, low-salt diet; increasing physical activity and starting a structured exercise program; limiting alcohol consumption; reducing stress and stopping smoking. Those kinds of lifestyle changes have been shown in several studies to have a significant decrease in both systolic and diastolic blood pressure,” Kamath says.
Another piece of the puzzle, she notes, is identifying and treating underlying conditions that might be causing high blood pressure. “A prevention-based, proactive effort needs to be made on the patient and provider front,” Kamath notes. “That includes starting with basic testing after a primary hypertension diagnosis. I’ll order a complete blood count, metabolic panel, blood glucose count, cholesterol test, thyroid check, a urinalysis and an EKG.”
This combination of strategies, along with medications for hypertension, gives you the best chance of getting your blood pressure down to a normal or manageable range and living a healthier life.
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Update 07/15/21: This piece was previously published at an earlier date and has been updated with new information.