For Uncontrolled Blood Pressure, is it Better to Add a Pill or Increase the Dose of the Current Ones

Goals for blood pressure have declined over the years. As the target blood pressure decreases, a patient may require more blood pressure therapy to achieve goal. There are two strategies to achieve goal. We frequently use both approaches. We will explain the preferred method and why we like it.

Let’s start with an example patient with hypertension who is on lisinopril at 10 mg daily and hydrochlorothiazide at 12.5 mg daily. The blood pressure is 160/89 or too high. We need to get the blood pressure lower.

What is our next step? One approach we can offer is to increase the dose of the medication the patient is currently taking. The patient is on a low dose of lisinopril and a low dose of hydrochlorothiazide. Increasing the dose of either medication will lower the blood pressure. The second approach we can offer is to add a medication from another class of antihypertensives. Which strategy will improve the patient’s blood pressure more?

Reviewing the medicines the patient takes, as we have already stated, we can see the patient is on an ACE inhibitor (lisinopril) and a diuretic (hydrochlorothiazide). If we decide to add from a different class of antihypertensives, which class should we pick? (See the figure below.) An example of another class of antihypertensives we might consider in this patient is the calcium channel blocker class. Medications in the calcium channel blocker class include amlodipine (also known as Norvasc) and diltiazem.

Prior to deciding the next step, we providers need to take the entire clinical situation into consideration. Some guidelines would suggest maximizing a particular class of blood pressure pill to benefit the patient even if we will not see much improved blood pressure control when used at a higher dose. For example, ACE inhibitors (lisinopril) and angiotensin receptor blockers (ARBs such as losartan) are powerful anti-protein in the urine medications and can help prevent chronic kidney disease when given at the highest tolerated dose.

So if the patient we serve has diabetes, my next step would be to increase the lisinopril to 40 mg daily. It is important to appreciate that as we increase a dose of a medication to the maximum tolerated, there is still a blood pressure lowering effect, but the blood pressure lowering is less than adding a medication from another class. We are very unlikely to achieve goal increasing the lisinopril to 40 mg daily. We require too much blood pressure reduction.

Our next step is to consider increasing the hydrochlorothiazide or adding the amlodipine. Adding the third class, the amlodipine, will lead to a better blood pressure reduction than increasing the hydrochlorothiazide. I would choose this approach more often.

However, there are many permutations on this theme. Some variations to consider: should we switch the patient to chlorthalidone, a stronger diuretic blood pressure medication than hydrochlorothiazide? Did we pick the best class and best-in-class medication in the categories we can pick from to add on to this patient’s blood pressure regimen? If the patient has heart failure or chronic kidney disease, do we need to consider SGLT2 medications? We associate the SGLT2 medication class with weight loss. Decreased weight occurs when a patient takes a SGLT2 because these medications cause up to 100 grams of sugar to spill into the urine daily. With weight loss comes blood pressure reduction. The following figure shows some recommended combinations. Note the only not recommended combination is combining ACE inhibitors and angiotensin receptor blockers or ARBs.

Blood pressure medication combinations to consider when treating patients with hypertension. This is a guide.

We like to individualize our strategy based on the individual patient sitting in our clinic. That said, a general rule of thumb we ask of you to consider is to allow us to add yet another pill to your regimen. You may encounter fewer side effects with this approach and achieve your target blood pressure more easily.