Finding the “Best” High Blood Pressure Medication for You
The list of drugs and drug combinations most commonly used to treat hypertension (high blood pressure) is remarkably long.
Choosing the Right Treatment
Doctors generally use a systematic approach to selecting the optimal therapy for hypertension.
Step 2: If these lifestyle measures do not result in sufficient blood pressure control after several weeks, it is usually time to add drug therapy.
Drug Therapy Approaches
There are five major categories of drugs that have been proven effective in treating hypertension. These are:
- Thiazide diuretics
- Angiotensin-converting enzyme (ACE) inhibitors
- Calcium blockers
- Angiotensin receptor blockers (ARBs)
In “guessing” on the best initial single drug to try, most experts now recommend beginning either with either a thiazide diuretic (usually chlorthalidone or hydrochlorothiazide), a long-acting calcium blocker, or an ACE inhibitor. ARBs are generally thought of as substitutes for ACE inhibitors, and generally, are used only when ACE inhibitors are poorly tolerated.There are no hard and fast rules about which drugs to use in which people, but there are certain tendencies that are useful in selecting single-drug therapy:
- Younger patients more often respond well to ACE inhibitors.
- Black patients and elderly patients tend to do better with thiazide diuretics or calcium channel blockers.
- Black patients tend to do poorly with ACE inhibitors.
- Beta blockers are usually a relatively poor choice for single-drug therapy and are generally used only if there is another medical reason to use beta-blockers (such as the need to treat angina or heart failure, or to control the heart rate in a person with atrial fibrillation).
Combination Drug Therapy: Using more than one medication to treat hypertension is necessary under two conditions. First, combination therapy is used in people who have stage 1 hypertension and at least two or three unsuccessful attempts have been made to treat their blood pressure with single-drug therapy.Second, combination drug therapy is used in people who have stage 2 hypertension (that is, their systolic pressure is 160 mm Hg or higher, or their diastolic pressure 100 mm Hg or higher.) Single-drug therapy is extremely unlikely to work in these people, so combination therapy is usually selected from the outset.With so many drugs to choose from, how can doctors ever decide which drugs to combine? Thankfully, several clinical trials have been conducted that offer substantial guidance in choosing appropriate combination therapy for hypertension.
The best evidence (from the ACCOMPLISH trial) suggests that clinical outcomes (including the risk of stroke, heart attack, and cardiovascular death) are most improved with combination therapy when a long-acting calcium blocker is used together with an ACE inhibitor or an ARB. So, today most doctors will try this combination first.If the blood pressure remains elevated with combination therapy using a calcium blocker plus an ACE or ARB drug, a thiazide drug will usually be added as a third drug. And if this combination still fails to control the blood pressure, a fourth drug (usually spironolactone, a non-thiazide diuretic) may be added.The vast majority of patients with hypertension will achieve successful therapy long before a third or fourth drug needs to be considered. The rare individual who fails to respond adequately to this kind of combination therapy should be referred to a hypertension specialist.
Avoiding Adverse Effects
Any of the drugs used to treat hypertension has the potential of causing problems. And when choosing the “best” drug regimen for treating a person with hypertension, it is critical to find a drug (or drugs) that not only effectively reduce the blood pressure, but that also is well tolerated.
It has been very helpful that using low doses of hypertension drugs is as effective as using higher doses. The ability to get by with low doses greatly reduces the risk of adverse effects.
Still, these drugs can cause problems, and it is important for you to be aware of the potential adverse effects. While each of the myriads of hypertension drugs has its own individual “side effect profile,” for the most part the potential adverse effects of these drugs are related to their category. The major category-related adverse effects are:
- Thiazide diuretics: hypokalemia (low potassium levels), frequent urination, worsening of gout
- ACE inhibitors: a cough, loss of sense of taste, hyperkalemia (elevated potassium levels)
- Calcium blockers: constipation, swelling of the legs, headache
- Beta blockers: worsening of dyspnea in people with chronic obstructive pulmonary disease or asthma, sexual dysfunction, fatigue, depression, worsening of symptoms in people with peripheral artery disease
- ARBs: allergic reactions, dizziness, hyperkalemia
With so many drugs to choose from, it is rare that a doctor will ask a person with hypertension to tolerate significant adverse effects. if you are being treated for hypertension and you are experiencing any troublesome side effects, you should certainly talk to your doctor about finding a treatment regimen that you can tolerate better.
As noted at the beginning of this article, the list of drugs that have been approved for the treatment of hypertension is quite long. Here is a reasonably complete listing of these drugs. The generic name of each drug is listed first, followed by the trade names.
- Acetazolamide – Diamox
- Chlorthalidone – Thalidone, also sold as Tenoretic and Clorpres
- Hydrochlorothiazide – HydroDiuril, also sold as Microzide and Esidrix
- Indapamide – Lozol
- Metolazone – Zaroxolyn, also sold as Mykrox
Diuretics less commonly used for hypertension:
- Amiloride hydrochloride – Midamor
- Bumetanide – Bumex
- Ethacrynic acid – Edecrin
- Furosemide – Lasix
- Spironolactone – Aldactone
- Torsemide – Demadex
- Triamterene – Dyrenium
Beta-blockers: Beta-blockers block the effect of adrenaline on the cardiovascular system, slow the heart rate, and reduce stress on the heart and the arteries.
- Acebutolol – Sectral
- Atenolol – Tenormin
- Betaxolol – Kerlone
- Bisoprolol – Zebeta, also sold as Ziac
- Carteolol – Cartrol
- Carvedilol – Coreg
- Labetalol – Normodyne, also sold as Trandate
- Metoprolol – Lopressor, also sold as Toprol
- Nadolol – Corgard
- Penbutolol – Levatol
- Propranolol – Inderal, Inderal LA
- Timolol – Blocadren
Calcium Channel Blockers: Calcium channel blockers can reduce blood pressure by dilating the arteries and, in some cases, reducing the force of the heart’s contractions.
- Amlodipine – Norvasc, also sold as Caduet and Lotrel
- Diltiazem – Cardizem, also sold as Dilacor and Tiazac
- Felodipine – Plendil
- Isradipine – DynaCirc
- Nicardipine – Cardene
- Nifedipine – Procardia XL, also sold as Adalat
- Nisoldipine – Sular
- Verapamil hydrochloride – Isoptin, also sold as Calan, Verelan, and Covera
Angiotensin Converting Enzyme Inhibitors: The angiotensin-converting enzyme inhibitors (the “ACE inhibitors”) can lower blood pressure by dilating the arteries.
- Benazepril – Lotensin
- Captopril – Capoten
- Enalapril – Vasotec, also sold as Vaseretic
- Fosinopril – Monopril
- Lisinopril – Prinivil, also sold as Zestril
- Moexipril – Univasc
- Quinapril – Accupril
- Ramipril – Altace
- Trandolapril – Mavik
- Candesartan – Atacand
- Irbesartan – Avapro
- Losartan – Cozaar
- Telmisartan – Micardis
- Valsartan – Diovan
Other, Less Commonly Used Hypertension Drugs
- Clonidine – Catapres
- Doxazosin – Cardura
- Guanabenz – Wytensin
- Guanfacine – Tenex
- Hydralazine hydrochloride – Apresoline
- Methyldopa – Aldomet
- Prazosin – Minipress
- Reserpine -Ã‚Â Serpasil
- Terazosin – Hytrin
- Amiloride and hydrochlorothiazide – Moduretic
- Amlodipine and benazepril – Lotrel
- Atenolol and chlorthalidone – Tenoretic
- Benazepril and hydrochlorothiazide – Lotensin HCT
- Bisoprolol and hydrochlorothiazide – Ziac
- Captopril and hydrochlorothiazide – Capozide
- Enalapril and hydrochlorothiazide – Vaseretic
- Felodipine and enalapril – Lexxel
- Hydralazine and hydrochlorothiazide – Apresazide
- Lisinopril and hydrochlorothiazide – Prinzide, also sold as Zestoretic
- Losartan and hydrochlorothiazide – Hyzaar
- Methyldopa and hydrochlorothiazide – Aldoril
- Metoprolol and hydrochlorothiazide – Lopressor HCT
- Nadolol and bendroflumethiazide – Corzide
- Propranolol and hydrochlorothiazide – Inderide
- Spironolactone and hydrochlorothiazide – Aldactazide
- Triamterene and hydrochlorothiazide – Dyazide, also sold as Maxide
- Verapamil extended release) and trandolapril – Tarka
A Word From Verywell
Hypertension is an extremely common medical problem that can have severe consequences if it is not treated adequately. However, with so many treatment options, you should expect your doctor to find a therapeutic regimen that will greatly decrease your risk of a bad outcome from hypertension, without disrupting your everyday life.