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Initial Antihypertensive

Discussion in 'Family Medicine' started by DOAnestMan, Jul 27, 2006.

  1. DOAnestMan

    DOAnestMan Junior Member
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    Hey all-
    I was wondering if anyone had suggestions regarding initial treatment of primary hypertension with an ACEI/ARB. I am seeing what people have had the best success with. For the purpose of this, let's just assume that insurance will cover whatever drug prescribed. Thanks.
     
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  3. EP to FP

    EP to FP Junior Member
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    I would not initiate therapy for primary HTN with an ACE/ARB unless the patient is diabetic or is spilling some protein in the urine. Unless contraindicated (i.e., low K+, severe renal dysfunction, etc.) I always begin with HCTZ. It's cheap and usually works pretty well. I've seen patients who have uncontrolled HTN and are on an ACE/B-blocker/Calcium channel blocker and I'll add 12.5mg of HCTZ which will do the trick.

    If your question is to use an ACE vs. an ARB, I would choose the ACE first. More research has been done on ACE-I, lisinopril is cheap, and usually works quite well.
     
  4. dr.smurf

    dr.smurf Senior Member
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    on which stage of htn. jnc 7 says that a pt in stage 1 htn class (systolic 140-159 and diastolics 90-99) should be started on 1 agent first. it is true that hydrochlorothiazide is a first line start drug that is safe and effective to various degrees for most, and cheap.

    however, pts with sbp > or = to 160 and dbp > or = to 100 are stage 2 and these pts are to be started on 2 agents from the get go. this is where your combination drug comes to play. this can be either an ace inhib, bb, or arb. there is more and more evidence that ace-i's are great first line agents. they have little to no sexual side effects like beta blockers, renal protection, may help with insulin resistance by mechanisms not fully understood, etc.

    here is the actual report from jnc 7. http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf
     
  5. Blue Dog

    Blue Dog Fides et ratio.
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    Barring any compelling reason to do otherwise, I tend to use generic ACE inhibitors as first-line therapy. If the patient coughs, I'll change to an ARB. HCTZ is second-line, in my book...I don't care what ALLHAT says (who uses chlorthalidone, anyway?) HCTZ causes as much ED as a beta-blocker. If you really hate a guy, put him on Inderide. ;)
     
  6. ntubebate

    ntubebate Country Doctor
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    My first line drug always has been and until the ARB's go generic, will continue to be PRINIVIL (Lisinopril).

    It's dirt cheap, works great and a patient told me that K-Mart is now selling a three month supply for $15, regardless of insurance.
    Five bucks a month for one of the most researched and best documented anti-hypertensives sounds good to me!

    ntubebate
     
  7. stoic

    stoic "Time you enjoy wasting, was not wasted"
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    actually, i had an attending this summer who used a lot of chlorthalidone. his pt's generally did well on it and it is dirt cheap.

    generally i'm inclined towards HCTZ and or lisinopril as a first line agent/combo depending on htn severity. i've also seen several pt's who didn't respond especially well to acei/hctz respond very well the an arb/hctz combo.

    i did work with a doc for a short time who liked to start beta-blockers as initial therapy for mild/moderate htn. i never really understood that as the literature doesn't really support doing so and his patients as a rule had marginal control at best... he wrote for more toprol than any doc i've ever been around.

    anyhow, i tend to use beta-blockers very sparingly (or rather suggest their use sparingly) unless there is a cardiac history.

    are beta-blockers the DOC for episodic, symptomatic htn (regardless of baseline bp and meds). ie if someone has mild/moderate htn that is generally well controlled, but has pulsating headaches associated with stress a couple times a week do you like to add a prn beta-blocker or is a regularly scheduled dosing better?
     
  8. Blue Dog

    Blue Dog Fides et ratio.
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    I read one study recently (Ref: http://hyper.ahajournals.org/cgi/content/abstract/47/3/352 ) comparing chlorthalidone to HCTZ, and it suggested that chlorthalidone, due to a longer elimination half-life, might provide greater 24-hour BP control than HCTZ.

    However, most of the readily-available drug combinations use HCTZ, not chlorthalidone. That's the main reason it's used more often.

    Beta-blockers are frequently used as prophylaxis for chronic migranous (migraines or migraine variant) headaches, but I've never used them on a prn basis.
     
  9. ntubebate

    ntubebate Country Doctor
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    I think I probably fall in second. If control cannot be attained with Prinivil (Lisinopril) +/- HCTZ then Toprol is my next choice. Also, FWIW, they are shipping generic Toprol (Metoprolol) to the pharmacies as we speak.

    ntubebate
     
  10. ntubebate

    ntubebate Country Doctor
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