The following information was adapted from the National Institute of Clinical Excellence (NICE) guidance for management of high blood pressure. It is a quick reference tool for the general public and sincere efforts have been made to simplify medical terminology. Health professionals may find it useful as a quick reference guide also.

Patients younger than 55 years old

Option 1:

1 (a): RAMIPRIL, ENALAPRIL, PERINDOPRIL etc.

1 (b): LOSARTAN, CANDESARTAN etc.

1 (c): This is mainly for young female patients who are still within child-bearing age. LABETALOL or any other of a    

similar class is recommended. Other YOUNG patients, for example, those who stop taking a drug from 1a or 1c above due to severe side-effects may be given ATENOLOL, BISOPROLOL or similar agents.

Some patients in this group have hypertension and sympathetic symptoms such as palpitations (abnormal rapid beating of the heart, rapid pulse or throbbing). Your clinician will diagnose your condition, tell you the available options, and of course support your informed choice.

Patients older than 55 years old

Option: 1

1 (a) for this groups is AMLODIPINE, NIFEDIPINE, NICARDIPINE and other similar drugs.

1 (b) for this group of patient is CHLORTHALIDONE or INDAPAMIDE "modified release" tablets.

Option 2:  When TWO drugs are required for adequate blood pressure control.

2 (a): A Calcium Channel Blocker such as AMLODIPINE plus angiotensin II receptor blockers (ARBs) such as LOSARTAN, EPROSARTAN are recommended.

2 (b) When ARBs are not suitable angiotensin converting enzyme (ACE) inhibitors like, RAMIPRIL, ENALAPRIL may be recommended.

2 (c) Calcium channel blockers (CCBs) like AMLODIPINE may cause significant water retention around the foot and ankles - a phenomenon commonly referred to as oedema. If AMLODIPINE is not tolerated or considered clinically inappropriate CHLORTHALIDONE or INDAPAMIDE may be recommended in its place. 

Option 3:  

When a combination of THREE drugs are required to control high blood pressure ARBs + CCBs + Thiazide-like Diuretics are recommended. See examples of agents above.

Option 4:  

After all options above have been utilized as BEST possible and blood pressure remains greater than 140/90 mmHg it may be considered TREATMENT RESISTANT.

4 (a) Seek the assistance of a specialist doctor in the management of hypertension.

4 (b) A medicine known as SPIRONOLACTONE may be added as a fourth drug in a multiple treatment therapy plan if a patient's blood potassium level are at the lower end of the acceptable range. For patients with potassium levels at the higher end of the scale the dose of CHLORTHALIDONE or INDAPAMIDE may be increased.

4 (c)  Add Alpha-Blockers like DOXAZOSIN

For people of African heritage LOSARTAN or EPROSARTAN or similar drugs plus AMLODIPINE or FELODIPINE or similar medications are recommended. This is because patients of African ancestry may have low levels of an enzyme called RENIN which is essential for drugs like RAMIPRIL or ENALAPRIL to work effectively. In other words drugs like RAMIPRIL and ENALAPRIL are not as effective as other drug classes in reducing blood pressure in people of African origin. 

For accurate information on your medicines always consult your pharmacist. Clinical management decisions should always be made in conjunction with your doctor. The examples and stepwise treatment plan may differ outside the United Kingdom. The information in this review was adapted from the National Institute of Clinical Excellence (NICE) guidance -CG127.

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