Find A Physician

Return to Recent Refinements in Use of Blood Pressure Medications Overview

More on Recent Refinements in Use of Blood Pressure Medications

Newsroom

Return to Recent Refinements in Use of Blood Pressure Medications Overview

More on Recent Refinements in Use of Blood Pressure Medications


Research and Clinical Trials

Return to Recent Refinements in Use of Blood Pressure Medications Overview

More on Recent Refinements in Use of Blood Pressure Medications

Clinical Services

Return to Recent Refinements in Use of Blood Pressure Medications Overview

More on Recent Refinements in Use of Blood Pressure Medications

Recent Refinements in Use of Blood Pressure Medications

NEW YORK (Mar 1, 2012)

Samuel J. Mann, M.D.
Samuel J. Mann, M.D.

From Samuel J. Mann, M.D. –

Doctors who treat patients with high blood pressure now have dozens of effective antihypertensive medications to choose from. The bad news, though, is that about 30 percent of the people who take these medications still have uncontrolled hypertension, and, with so many drugs now available, the pharmaceutical industry is less interested in investing in the discovery of new antihypertensive drugs. So we've got to do better with the medications we have.

Based on our experience, it is our belief that we can do much, much better with the drugs we already have. Here are several refinements, reported in recent studies, that can help optimize the use of blood pressure medication:

Diuretics: In the past, many doctors prescribed high doses of diuretics, but these were accompanied by a range of side effects, such as depletion of potassium and magnesium. More recently the use of lower doses, such as 25 mg of the most widely prescribed diuretic, hydrochlorothiazide, has been the rule. But recent studies and papers emphasize that this dose is too low for many people whose hypertension is not controlled by medication, and that a higher dose (37.5 or 50 mg) may be needed. An alternative is to add a potassium-sparing diuretic, such as spironolactone or eplerenone or amiloride, which help control BP without depleting potassium. The use of chlorthalidone, a more potent diuretic than hydrochlorothiazide, has also been advocated in recent reports.

Beta-blockers: Beta-blockers are effective, but many patients experience side effects (fatigue, erectile dysfunction, cold extremities, and more). How do we get around this? The good news is that in most cases, an angiotensin-converting-enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) works just as well as a beta-blocker without the side effects, and provides better protection against stroke and heart attack! In other words, many patients who are taking a beta-blocker and are suffering side effects don't need to be on one. For some patients, though, a beta-blocker is exactly the right drug. In our research, we have found that the combination of a beta-blocker and an alpha-blocker – a combination that is not widely used – is extremely effective, particularly in patients whose hypertension is driven by the sympathetic nervous system rather than by the kidneys.

One very interesting observation that few doctors are aware of: in some cases, beta-blockers can cause reversible cognitive dysfunction, mental dullness, and/or memory loss. If you or someone you know has experienced such effects after starting a beta-blocker, particularly a beta-blocker that penetrates into the brain, stopping the drug, under supervision of a physician, can sometimes lead to dramatic improvement within a few days. There are no controlled trials regarding this problem, but dramatic clinical observations suggest it is worth a try, again, under supervision.

Most beta-blockers constrict arteries. Newer beta-blockers (carvedilol; Coreg and nebivolol; Bystolic) dilate arteries, which is physiologically preferable. Do vasodilating beta-blockers confer greater advantage in the long run? Maybe, although the studies to prove this remain to be done.

Drugs that should usually be avoided: Clonidine (Catapress) is very effective, but most patients experience fatigue, dry mouth, and sexual dysfunction. If you are taking clonidine and are having side effects that bother you, there is a good chance that other drugs can control your blood pressure without these side effects.

Drug combinations: A combination of two drugs is likely to lower blood pressure significantly more than a single drug. However, some combinations lower blood pressure more than others.

Effective combinations include:

  • an ACEI or ARB combined with either a diuretic or calcium channel blocker (CCB)
  • a beta-blocker combined with an alpha-blocker

Less effective combinations include:

  • an ACEI combined with an ARB
  • an ACEI or ARB combined with a DRI

Recently Valturna, a combination of valsartan (Diovan) and aliskiren (Tekturna) was taken off the market because it not only lowered blood pressure less than other combinations, but also provided no added benefit compared to either drug alone.

The good news is that with better use of the medications we already have, hypertension can be controlled in nearly all patients, and usually without side effects. Current research at our Hypertension Center focuses on how best to treat hypertension in patients with "resistant hypertension," defined as hypertension that has not come under control on a regimen of 3 or more medications. In one study, we are looking at the effectiveness of two individualized drug combinations in normalizing the blood pressure. Preliminary studies have been very encouraging. Another study, which will begin shortly, will employ a new treatment modality, renal nerve ablation, which via a catheter, interrupts the flow of nerve traffic to the kidneys. In preliminary studies this procedure appears safe and extremely effective in patients whose hypertension cannot otherwise be controlled.

We will shortly begin accepting patients with "resistant" hypertension for participation in these two studies. For more information, please can contact the Hypertension Center at 212-746-2200.

Samuel J. Mann, M.D., is an Attending Physician at New York-Presbyterian/Weill Cornell Medical Center and a Professor of Clinical Medicine at Weill Cornell Medical College. He is the author of an upcoming book: Hypertension and You: Old Drugs, New Drugs, and the Right Drugs for your High Blood Pressure.

  • Bookmark
  • Print

    Find a Doctor

Click the button above or call
1 877 NYP WELL


eNewsletters


Newsroom


Clinical Services


Top of page