The most important aspect of a blood pressure medication is half-life. I generally use the American Society of Hypertension guidelines, slightly adjusted to fit individual patient needs. They write the board exam for HTN, and their recd are very different from the standard practice, which is what you are on (we forgot to mention the ubiquitous - and terrible - hydrochlorothiazide.Originally Posted by David Kirkham
The basic algorithm is this: start with an ARB (not losartan, it is worst-in-class). Skip ACE inhibitors completely because ARBs are better anyway and there is a not insignificant chance of life threatening angioedema with ACEi, also other side effects such as cough, which ARBs don't share. Olmesartan and telmisartan are good (because of long half-life and greater target receptor activity (fewer side effects).) If another drug is required, a calcium channel blocker is next (pretty much only choice is amlodipine). Next up is a thiazide diuretic (not HCTZ). Generally chlorthalidone, which is what most of the research was done with anyway (very few studies used HCTZ, so using it is not evidence based, which is supposed to be what people care about, but then they all go and use HCTZ - and it has a shit ton of side effects). Next up would be an aldosterone antagonist, such as spironolactone or eplerenone (which has the added benefit of countering the potassium wasting effects some people experience with thiazides. Only if all this is still not working do you add a beta-blocker (not metoprolol!) You want one with alpha effect for peripheral vasoconstriction, such as carvedilol (and at this point you would also be screening them for aldosteronism.)
These are the guidelines. Of course this is not medical advice, because internet and I might not even be a doctor. So there you have it.
