Lifestyle changes, including dietary adjustments and regular exercise, are by far the most important factors in controlling blood pressure. However, a combination of therapies, including antihypertensives, is often needed.
Regardless of the cause of high blood pressure, there is a wide range of medications available to treat it. These are typically used in stages until a personalized treatment plan that works for each hypertensive patient is found.
The main types of medications used in the treatment of high blood pressure are:
Diuretics are often the first choice for treating high blood pressure.
Diuretics increase the elimination of urine and salt from the body, which helps lower blood pressure both by reducing fluid volume and by decreasing resistance to blood flow in the blood vessels.
After taking diuretics, you may notice that you urinate more frequently and more quickly after consuming liquids.
The side effects of diuretics are typically minimal, but one notable concern is the loss of potassium (hypokalemia). This requires monitoring potassium levels in the blood through regular testing and, in some cases, taking potassium supplements. Dietary sources of potassium, such as oranges or bananas, are usually insufficient to correct deficiencies caused by diuretics. Additionally, reducing salt intake can enhance the effectiveness of diuretics and minimize potassium loss.
The main types of diuretics used to treat high blood pressure are:
Indications for diuretics in high blood pressure
Classification of diuretics, dosage and duration of action
Group | Name | Dose (mg/day) | Duration of action (h) |
---|---|---|---|
Thiazides | Chlorothiazide | 125-500 | 6-12 |
Hydrochlorothiazide | 12,5-50 | 12-24 | |
Chlorthalidone | 12,5-50 | 24-48 | |
Indapamide | 1,25-5 | 24 | |
Metolazone | 0,5-10 | 24 | |
Bendroflumethiazide | 2,5-5 | 24 | |
Loop diuretics | Furosemide | 20-480 | 8-12 |
Ethacrynic acid | 25-100 | 12 | |
Bumetanide | 0,5-5 | 8-12 | |
Piretanide | 3-6 | 6-8 | |
Potassium-sparing diuretics | Spironolactone | 25-100 | 8-24 |
Triamterene | 50-150 | 12-24 | |
Amiloride | 5-10 | 12-24 |
Beta-blockers work by blocking many of the effects of adrenaline in the body, particularly its stimulating effects on the heart. This causes the heart to beat more slowly and with less force. Specifically, beta blockers act by inhibiting the effects of adrenaline on beta-adrenergic receptors in the body.
There are two types of beta receptors:
By taking beta blockers, the heart beats more slowly and exerts less force, helping to reduce blood pressure.
Beta blockers are primarily used for their antihypertensive effect (to treat high blood pressure). However, they are also used as:
Types of beta blockers:
Effects of beta blockers on high blood pressure:
Common side effects of beta blockers include tiredness, dizziness, headache, cold hands and feet, bradycardia (low heart rate), etc.
Beta blockers are particularly indicated in cases of:
Classification of beta blockers
Name | Dose (mg/day) | Duration of action (h) |
---|---|---|
Atenolol | 25-100 | 24 |
Bisoprolol | 5-20 | 24 |
Metoprolol | 5-200 | 12-24 |
Nadolol | 20-240 | 24 |
Oxprenolol | 30-240 | 8-12 |
Propranolol | 40-240 | 8-12 |
Labetalol | 200-1200 | 8-12 |
Carvedilol | 50-50 | 12-24 |
Calcium channel blockers, prevent calcium from entering cells. This reduces the tendency of small arteries to narrow, decreases myocardial contractility, and lowers peripheral vascular resistance.
There are two types of calcium channel blockers:
As side effects, the following ones are described: oedema (ankle swelling), flushed skin and headache, orthostatic hypotension, constipation and bradycardia (very slow heart rate).
Calcium channel blockers are particularly indicated in cases of:
Classification of calcium channel blockers, dosage and duration of action
Group | Subgroup | Name | Dose (mg/day) | Duration of action (h) |
Dihydropyridines | First generation | Nifedipine | 30-120 | 8 |
Second generation | Amlodipine | 2,5-10 | 24 | |
Felodipine | 5-40 | 24 | ||
Nitrendipine | 10-40 | 24 | ||
Lacidipine | 4 | 24 | ||
Nicardipine | 20-40 | 12-16 | ||
Isradipine | 25 | 12-16 | ||
Third generation | Manidipine | 10-20 | 24 | |
Benzothiazepines | Diltiazem | 90-360 | 8 | |
Phenylalkylamines | Verapamil | 80-480 | 8 |
1. Angiotensin-Converting Enzyme Inhibitors (ACEIs)
Similar to calcium channel blockers, ACE inhibitors reduce the tendency of small arteries to narrow, but they work through a different mechanism.
ACE inhibitors prevent the production of angiotensin II, a substance in the body that raises blood pressure and causes blood vessels to constrict. Without angiotensin II, renin levels are regulated, helping to lower blood pressure and reduce vascular resistance.
ACE inhibitors are commonly prescribed for:
The most frequently reported side effects include cough, hypotension (low blood pressure), headaches, angioedema, skin rashes and increased urea levels.
ACE inhibitors should not be used in pregnant women or women at risk of pregnancy and individuals with renal artery stenosis.
Classification with dose and duration of action of ACEIs
Group | Name | Dose (mg/day) | Duration of action (h) |
Sulfhydryl group | Captopril | 12,5-150 | 6-12 |
Carboxyl group | Enalapril | 5-40 | 12-24 |
Benazepril | 10-20 | 10-20 | |
Cilazapril | 2,5-5 | 12-24 | |
Lisinopril | 5-40 | 12-24 | |
Perindopril | 2-16 | 12-24 | |
Quinapril | 5-80 | 12-24 | |
Ramipril | 2,5-5 | 12-24 | |
Trandolapril | 2,5-5 | 12-24 | |
Phosphoryl group | Fosinopril | 5-40 | 12-24 |
2. Angiotensin II receptor blockers (ARBs)
Angiotensin receptor blockers (ARBs) work in a manner similar to ACE inhibitors (ACEIs) but are associated with fewer side effects.
One significant advantage of ARBs is that they can typically be taken once daily, improving convenience and adherence to treatment.
The most commonly used ARBs are losartan and valsartan.
3. Renin inhibitors
The medication from this group, aliskiren, was withdrawn in Europe due to its adverse effects, including heart and kidney problems, hypotension, and increased potassium levels in the blood.
It is recommended not to combine these three types of medications because there is no additional benefit in the treatment of high blood pressure. Moreover, the risk of undesirable effects, such as kidney damage and elevated potassium levels, is increased.
Alpha blockers, also called alpha adrenergic agonists, are used to treat hypertension as they promote the relaxation of small blood vessels, improve blood flow, and help reduce blood pressure.
There are two main types of alpha blockers:
Alpha blockers are typically considered second-line treatments for hypertension and are usually used in combination with diuretics.
In addition to lowering blood pressure, alpha blockers can help reduce "bad” or LDL cholesterol levels.
Alpha-1 blockers are also used to treat benign prostatic hyperplasia (BPH).
These medications act on the central nervous system and are now used less frequently.
Currently, alpha blockers are mainly recommended in specific combination therapies for treatment-resistant hypertension, where other medications have been ineffective.
The most common use of alphamethyldopa is during pregnancy.
Vasodilators
Vasodilators include medications such as hydralazine, minoxidil, diazoxide, and sodium nitroprusside.
These drugs work by directly relaxing the smooth muscles of the arterioles, causing them to dilate. This dilation can lead to reflex tachycardia (an increased heart rate) and salt retention. For this reason, they are typically used in combination with a diuretic and a beta blocker to counteract these side effects.
Hydralazine is often used as a third-line drug for hypertension. Careful dosing is necessary, as doses greater than 200 mg may increase the risk of a syndrome similar to lupus erythematosus.
Minoxidil can cause hypertrichosis (increased hair growth), but it is effective in cases of hypertension that are refractory to other treatments.
Sodium nitroprusside and diazoxide are used exclusively in hypertensive crisis.
Hydralazine and diazoxide have been used for severe arterial hypertension.
Nitroprusside is typically used in hypertensive emergencies when extremely high blood pressure poses an immediate threat to life.
Neprilysin and angiotensin receptor inhibitors (ARNIs)
This combination therapy includes sacubitril (a neprilysin inhibitor) and valsartan (an angiotensin receptor blocker, ARA II). The combination promotes peripheral vasodilation of the arteries, helping to lower blood pressure.
Show more