Choosing blood pressure medications

Choosing the right high blood pressure medication can be tricky. Find out which of the various drug options is appropriate for you.

Dozens of high blood pressure medications (antihypertensives) are available, each with pros and cons. Depending on how high your blood pressure is, your doctor may prescribe one or more high blood pressure medications to treat your condition. For everyone who has high blood pressure or is at risk of developing high blood pressure, lifestyle changes can help keep your numbers under control. Before beginning blood pressure treatment, it's a good idea to understand the options available to you.

Lifestyle changes

Whether you're on the road to developing high blood pressure (prehypertension) or you already have high blood pressure (hypertension), you can benefit from lifestyle changes that can lower your blood pressure. People who have prehypertension have a systolic pressure (top number) ranging from 120 to 139 millimeters of mercury (mm Hg) or a diastolic pressure (bottom number) ranging from 80 to 89 mm Hg.
Even if your doctor prescribes medications to control your blood pressure, he or she will likely recommend you make lifestyle changes as well. Lifestyle changes can reduce or eliminate your need for medications to control your blood pressure. To make these changes:

• Don't smoke
• Eat a healthy diet, focusing on fruits, vegetables and low-fat dairy products, and especially, control the salt in your diet
• Maintain a healthy weight
• Exercise by getting 30 minutes of moderate activity — even if you need to break up your activity into three 10-minute sessions — on most days of the week
• Limit the amount of alcohol you drink — one drink a day for women and two a day for men

You probably won't need to take high blood pressure medications if you have prehypertension and are otherwise healthy. However, if you have prehypertension and diabetes, kidney disease or heart disease, your doctor might prescribe medications to lower your blood pressure to a more desirable level.

Medication options for stage 1 high blood pressure (140/90 to 159/99)

If you have stage 1 high blood pressure, you have a systolic pressure ranging from 140 to 159 mm Hg or a diastolic pressure ranging from 90 to 99 mm Hg. If both numbers are in this range, you also have stage 1 high blood pressure. The first change you can make is to adopt healthy lifestyle changes to help decrease your numbers. Your doctor will likely prescribe medications, as well.
Diuretics (water pills)Your doctor may first suggest diuretics — also called water pills. Diuretics work by flushing excess water and sodium from the body, thus lowering blood pressure, which may be enough along with lifestyle changes to control your blood pressure.
Although three types of diuretics are available, the first choice is usually a thiazide diuretic. Thiazide diuretics typically have fewer side effects than do other types of diuretics. They also offer strong protection against conditions that high blood pressure can cause, such as stroke and heart failure.
Other medicationsA diuretic may be the only high blood pressure medication you need. But under some circumstances, your doctor may also recommend another medication or may add another medication. Those choices include:

• Angiotensin-converting enzyme (ACE) inhibitors. These allow blood vessels to widen by preventing a hormone called angiotensin from affecting blood vessels. Frequently prescribed ACE inhibitors include captopril (Capoten), lisinopril (Prinivil, Zestril) and ramipril (Altace).
• Angiotensin II receptor blockers. These help blood vessels relax by blocking the action of angiotensin. Frequently prescribed angiotensin II receptor blockers include losartan (Cozaar), olmesartan (Benicar) and valsartan (Diovan).
• Beta blockers. These work by blocking certain nerve and hormonal signals to the heart and blood vessels, thus lowering blood pressure. Frequently prescribed beta blockers include metoprolol (Lopressor, Toprol XL), nadolol (Corgard) and penbutolol (Levatol).
• Calcium channel blockers. These prevent calcium from going into heart and blood vessel muscle cells, thus causing the cells to relax, which lowers blood pressure. Frequently prescribed calcium channel blockers include amlodipine (Norvasc), diltiazem (Cardizem, Dilacor XR) and nifedipine (Adalat, Procardia).
• Renin inhibitors.  Renin is an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure. Aliskiren (Tekturna) slows down the production of renin, reducing its ability to begin this process. Due to a risk of serious complications, including stroke, you shouldn't take aliskiren with ACE inhibitors or ARBs.

Adding one of these medications can lower your blood pressure more quickly than can taking only a diuretic. This may reduce the risk of developing complications from high blood pressure. Combining two medications of different classes may allow you to take a smaller dose of each, which can reduce side effects and perhaps be less expensive. The choice of medications in combination depends on your individual circumstances.

Medication options for stage 2 high blood pressure (higher than 160/100)

If you have stage 2 high blood pressure, you have a systolic pressure of 160 mm Hg or higher or a diastolic pressure of 100 mm Hg or higher or both. In this case, you'll likely need to take at least two high blood pressure medications when you start treatment.
As with stage 1 hypertension, your doctor will likely prescribe a thiazide diuretic. Diuretics work by flushing excess water and sodium from the body, thus lowering your blood pressure. Along with a diuretic, your doctor may recommend that you also take:

• ACE inhibitors. This medication helps blood vessels relax by blocking the production of a hormone that causes blood vessels to narrow. Frequently prescribed ACE inhibitors include captopril (Capoten), lisinopril (Prinivil, Zestril) and ramipril (Altace).
• Angiotensin II receptor blockers. This medication allows blood vessels to widen by preventing a hormone called angiotensin from affecting vessels. Frequently prescribed angiotensin II receptor blockers include losartan (Cozaar), olmesartan (Benicar) and valsartan (Diovan).
• Beta blockers. This class of drugs works by blocking certain nerve and hormonal signals to the heart and blood vessels, thus lowering blood pressure. Frequently prescribed beta blockers include metoprolol (Lopressor, Toprol XL), nadolol (Corgard) and penbutolol (Levatol).
• Calcium channel blockers. This medication prevents calcium from going into heart and blood vessel muscle cells, thus causing the cells to relax, which lowers blood pressure. Frequently prescribed calcium channel blockers include amlodipine (Norvasc), diltiazem (Cardizem, Dilacor XR) and nifedipine (Adalat, Procardia).
• Renin inhibitors.  Renin is an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure. Aliskiren (Tekturna) slows down the production of renin, reducing its ability to begin this process. Due to a risk of serious complications, including stroke, you shouldn't take aliskiren with ACE inhibitors or ARBs.

If none of these medications is effective in lowering your blood pressure, your doctor may recommend another medication, such as an alpha blocker, central-acting agent or vasodilator. These medications are strong and may cause more side effects than may other blood pressure medications.
When your blood pressure is very high, it's important to reduce it quickly to prevent or delay complications, such as damage to your arteries, heart failure or kidney damage. A two-drug combination generally works faster than does a single drug to get your blood pressure under control. Sometimes a third medication, or more, may be needed to achieve your blood pressure goal.

High blood pressure and other health problems

High blood pressure often goes hand in hand with other health problems. If you have a serious health condition in addition to high blood pressure, it's likely you'll need aggressive treatment. Those conditions include:

• Heart failure
• Previous heart attack
• High risk of coronary artery disease
• Enlarged or thickened left chamber of the heart (left ventricular hypertrophy)
• Diabetes
• Chronic kidney disease
• Previous stroke

High blood pressure itself puts you at higher risk of having one of these conditions. If you already have one or more of these conditions plus high blood pressure, your chance of developing a life-threatening complication increases. A more aggressive treatment approach may reduce your risk of these complications.
Your doctor may recommend specific high blood pressure medications to treat these conditions, as well as additional medications for your high blood pressure. For example, if you have chest pain (angina), your doctor may recommend a beta blocker, which can lower your blood pressure and also prevent your chest pain, reduce your heart rate and decrease your risk of death. If you have diabetes and high blood pressure, taking a diuretic plus an ACE inhibitor can decrease your risk of heart attack and stroke. If you have diabetes, high blood pressure and kidney disease, you may need to add additional medications to the mix, such as an angiotensin II receptor blocker.

Keep trying to reach your blood pressure goal

Sometimes high blood pressure can be difficult to treat. If your high blood pressure doesn't decrease despite taking at least three different types of high blood pressure drugs, one of which should be a diuretic, you may have resistant hypertension. Resistant hypertension is blood pressure that's resistant to treatment. People who have controlled high blood pressure and are taking four different types of medications at the same time to achieve that control also are considered to have resistant hypertension.
It's not unusual to try several different medications or doses before finding what works best for you. In fact, if you and your doctor can identify what's behind your persistently high blood pressure, there's a good chance you can meet your goal with the help of treatment that's more effective. Home monitoring of your blood pressure can help your doctor decide if your blood pressure treatment is working, or if a different dose or medication is necessary.
In most cases, a combination of lifestyle changes and medication can help you successfully control your blood pressure. Once that's done, your doctor may recommend a gradual decrease in medications while monitoring the effect on your blood pressure; however, don't attempt to do this on your own.
Keeping your blood pressure under control may take some time, but in the long run it may mean a longer life, with fewer health problems