Choosing the Right Blood Pressure Medication

Making Sense of All the Choices

Choosing the right medication.
Choosing the right medication. Min-Chien Chang/moment/Getty Images

If you have hypertension (high blood pressure), and you have not been able to control it with changes in lifestyle (such as weight loss, exercise, and better eating habits), your doctor is very likely to prescribe drug therapy.

There are many, many drugs available for treating hypertension. There are so many drugs that, occasionally, settling on the “right" drug therapy can become a confusing process for both patients and their doctors.

Here is a reasonably complete list of the prescription drugs now being marketed for treating hypertension.

This is obviously a very long and daunting list of possibilities. Add to this the fact that effectively treating hypertension is often a trial-and-error proposition, and you can see why in many cases finding the “right” drug or drugs can seem quite confusing and difficult. However, most of the time such confusion and difficulty is unnecessary.

The good news is that, as long as your doctor follows a few basic principles and approaches the problem in a systematic way, he or she is very likely to achieve effective drug therapy for your hypertension fairly quickly, and with a minimum number of steps.

Some Basic Principles for Choosing Medical Therapy for Hypertension

Selecting the “right” medical treatment for your hypertension should depend, initially, on whether you have stage 1 or stage 2 hypertension.

1) Stage 1 hypertension. In stage 1 hypertension, your systolic pressure is less than 160 mm Hg, and your diastolic pressure is less than 100 mm Hg. If you have this relatively mild-to-moderate form of hypertension, treatment with a single drug is likely to be effective.

So, your doctor should begin with single-drug therapy, choosing a drug he/she feels is likely to work for you, and unlikely to cause you any side effects. If that first drug turns out to be inadequate, the next step should be a different - but still single - drug. This process should be repeated at least one or two more times if necessary. Only if several attempts at single-drug therapy are unsuccessful should your doctor finally try combination drug therapy.

2) Stage 2 hypertension. In stage 2 hypertension, your systolic pressure is 160 mm Hg or higher, or your diastolic pressure 100 mm Hg or higher. With this more severe form of hypertension, single drug therapy is unlikely to be effective. To achieve effective control of your blood pressure with a minimum of trial-and-error, your doctor generally should begin with combination drug therapy.

Single-Drug Therapy - Which Drug?

The drugs typically used to treat hypertension today fall into five major classes: 

In general, drugs from each of these classes (with the exception of beta-blockers) tend to work equally well in controlling hypertension.

Specifically, there is roughly a 50/50 chance that any particular drug will work adequately in a given person with stage 1 hypertension. However, individuals will respond quite differently to these medications. Jim might respond quite nicely to a thiazide, but fail with a calcium blocker, and the case with Jane might be the exact reverse. There’s generally no way ahead of time to predict which patient will do well with which kind of medication. So, what doctors and patients are left with is trial-and-error.

Most experts now recommend beginning either with a thiazide diuretic (usually chlorthalidone or hydrochlorothiazide), a long-acting calcium blocker, or an ACE inhibitor.

ARBs are generally thought of as substitutes for ACE inhibitors, when ACE inhibitors are poorly tolerated. There are no hard and fast rules about which drugs to use in which patients, but there are certain tendencies that are useful in selecting single-drug therapy:

  • Younger patients more often respond well to ACE inhibitors.
  • Black patients and elderly patients tend to do better with thiazide diuretics or calcium channel blockers.
  • Black patients tend to do poorly with ACE inhibitors.
  • Beta blockers are usually a relatively poor choice for monotherapy, and are generally used only if there is another medical reason to use beta blockers (such as the need to treat angina or heart failure, or to control the heart rate with atrial fibrillation).

In general, lower doses of blood pressure medicine are as effective as higher doses, and cause fewer side effects. So, when trying to find effective single-drug therapy, doctors usually begin with a low dose. They may decide to increase the dose a bit if the initial dose is ineffective - but doctors rarely “push” single-drug therapy into the higher dosage ranges. Instead, they should generally abandon a drug that fails to work at a relatively low dose, and switch to a low dose of a second drug.

Using this step-wise approach, about 80% of patients with stage 1 hypertension eventually can be treated adequately with a single hypertensive drug.

Combination Drug Therapy - Which Drugs?

Using more than one medication to treat hypertension is necessary under two conditions - if you have stage 2 hypertension, or if you have stage 1 hypertension and at least two or three unsuccessful attempts have been made to treat your blood pressure with single-drug therapy.

While numerous drug combinations are possible, recent evidence (from the ACCOMPLISH trial) suggests that clinical outcomes (including the risk of stroke, heart attack and cardiovascular death) are most improved when a long-acting calcium blocker is used together with an ACE inhibitor or an ARB. Most doctors will try this combination first, even if the patient had previously been taking a thiazide drug with partial success.

If combination treatment with a calcium blocker plus an ACE or ARB drug is still insufficient, a thiazide drug will usually be added as a third drug. And if this combination still fails to control the blood pressure, a fourth drug (usually spironolactone, a non-thiazide diuretic) may be added.

The vast majority of patients with hypertension achieve successful therapy long before a third or fourth drug needs to be considered. However, if your blood pressure remains poorly controlled after all these steps, you should talk to your doctor about a referral to a hypertension specialist.


Blood Pressure Lowering Treatment Trialists’ Collaboration, Turnbull F, Neal B, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008; 336:1121.

Jamerson KA, Bakris GL, Wun CC, et al. Rationale and design of the avoiding cardiovascular events through combination therapy in patients living with systolic hypertension (ACCOMPLISH) trial: the first randomized controlled trial to compare the clinical outcome effects of first-line combination therapies in hypertension. Am J Hypertens 2004; 17:793.

Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008; 359:2417.

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