The Drugs Commonly Used to Treat Blood Pressure

Finding the "Best" High Blood Pressure Medication for You

Doctor holding pills in hand
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The list of the drugs and drug combinations most commonly used to treat  hypertension (high blood pressure) is remarkably long.

The fact that there are so many drugs to choose from means at least two things. First, it means there is no “best” drug for hypertension, that is, there is no drug that works well in almost everyone without causing unacceptable adverse effects. If there were, drug companies would have stopped their efforts to develop new antihypertensive drugs long ago—and the list of approved drugs would be much shorter.

Second, with so many drugs to choose from, as long as you and your doctor are patient and persistent, it is extremely likely that an effective and well-tolerated treatment regimen will be found for your hypertension. In other words, while there is no universal “best” treatment for hypertension, there is likely to be a “best” treatment for you.

In this article, we will describe the kinds of drugs that are used for hypertension, and what steps your doctor should take in choosing (from the incredible array of options) your optimal treatment. Finally, we will provide a reasonably complete list of all the drugs currently used in the U.S. (and in most developed countries) for the treatment of hypertension.

Choosing the Right Treatment for Hypertension

Doctors generally use a systematic approach to selecting optimal therapy for hypertension.

Step 1: For people who have been diagnosed with mild or moderate hypertension, it is important to begin by recommending lifestyle changes that have been shown to help reduce blood pressure.

These include dietary changessalt restrictionregular exercise, and smoking cessation.

Step 2: If these lifestyle measures do not result in sufficient blood pressure control after several weeks, it is usually time to add drug therapy.

The Basic Approach to Choosing Drug Therapy for Hypertension

There are five major categories of drugs that have been proven effective in treating hypertension.

These are:

Single Drug Therapy

If you have stage 1 hypertension (where your systolic pressure is less than 160 mm Hg, and your diastolic pressure is less than 100 mm Hg), the general recommendation is to begin with a single drug from one of these five categories.

In general, drugs from each of these classes (with the exception of the beta-blockers, which are generally less effective as single drugs) tend to work equally well in controlling hypertension. Specifically, there is roughly a 50-50 chance that any particular drug will work adequately in any 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 is generally no way ahead of time to predict which person will do well with which kind of medication. So, what doctors and patients are left with is an educated trial-and-error approach.

In “guessing” on the best initial single drug to try, most experts now recommend beginning either with either 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, and generally are used only when ACE inhibitors are poorly tolerated.

There are no hard and fast rules about which drugs to use in which people, 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 single-drug therapy, 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 in a person 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 it is rarely useful to “push” the dose of single-drug therapy into the higher dosage ranges. Instead, if a drug fails to work at a relatively low dose, it is time to switch to a low dose of a different drug.

    Using this type of trial-and-error approach, about 80% of people with stage 1 hypertension eventually can be treated adequately with a single hypertensive drug.

    Combination Drug Therapy

    Using more than one medication to treat hypertension is necessary under two conditions. First, combination therapy is used in people who have stage 1 hypertension and at least two or three unsuccessful attempts have been made to treat their blood pressure with single-drug therapy.

    Second, combination drug therapy is used in people who have stage 2 hypertension (that is, their systolic pressure is 160 mm Hg or higher, or their diastolic pressure 100 mm Hg or higher.) Single drug therapy is extremely unlikely to work in these people, so combination therapy is usually selected from the outset.

    With so many drugs to choose from, how can doctors ever decide which drugs to combine? Thankfully, several clinical trials have been conducted that offer substantial guidance in choosing appropriate combination therapy for hypertension.

    The best evidence (from the ACCOMPLISH trial) suggests that clinical outcomes (including the risk of strokeheart attack and cardiovascular death) are most improved with combination therapy when a long-acting calcium blocker is used together with an ACE inhibitor or an ARB. So, today most doctors will try this combination first.

    If the blood pressure remains elevated with combination therapy using a calcium blocker plus an ACE or ARB drug, 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 will achieve successful therapy long before a third or fourth drug needs to be considered. The rare individual who fails to respond adequately to this kind of combination therapy should be referred to a hypertension specialist.

    Avoiding Adverse Effects From Hypertension Drugs

    Any of the drugs used to treat hypertension has the potential of causing problems. And when choosing the “best” drug regimen for treating a person with hypertension, it is critical to find a drug (or drugs) that not only effectively reduce the blood pressure, but that also are well tolerated.

    For this reason, it has been very helpful that using low doses of the hypertension drugs is as effective as using higher doses. The ability to get by with low doses greatly reduces the risk of adverse effects.

    Still, these drugs can cause problems, and it is important for you to be aware of the potential adverse effects. While each of the myriad of hypertension drugs has its own individual “side effect profile,” for the most part the potential adverse effects of these drugs are related to their category. The major category-related adverse effects are:

    With so many drugs to choose from, it is rare that a doctor will ask a person with hypertension to tolerate significant adverse effects. if you are being treated for hypertension and you are experiencing any troublesome side effects, you should certainly talk to your doctor about finding a treatment regimen that you can tolerate better.

    A List of the Most Commonly Used Hypertension Drugs

    As noted at the beginning of this article, the list of drugs that have been approved for the treatment of hypertension is quite long. Here is a reasonably complete listing of these drugs. The generic name of each drug is listed first, followed by the trade names.

    Diuretics

    Diuretics ("water pills") increase the amount of sodium and water excreted into the urine by the kidneys. It is thought that they lower blood pressure mainly by reducing the volume of fluid in the blood vessels.

    Diuretics commonly used for hypertension:

    • Acetazolamide - Diamox
    • Chlorthalidone - Thalidone, also sold as Tenoretic and Clorpres
    • Hydrochlorothiazide - HydroDiuril, also sold as Microzide and Esidrix
    • Indapamide - Lozol
    • Metolazone - Zaroxolyn, also sold as Mykrox

    Diuretics less commonly used for hypertension:

    • Amiloride hydrochloride - Midamor
    • Bumetanide - Bumex
    • Ethacrynic acid - Edecrin
    • Furosemide - Lasix
    • Spironolactone - Aldactone
    • Torsemide - Demadex
    • Triamterene - Dyrenium

    Beta-blockers

    Beta blockers block the effect of adrenaline on the cardiovascular system, slow the heart rate, and reduce stress on the heart and the arteries.

    • Acebutolol - Sectral
    • Atenolol - Tenormin
    • Betaxolol - Kerlone
    • Bisoprolol - Zebeta, also sold as Ziac
    • Carteolol - Cartrol
    • Carvedilol - Coreg
    • Labetalol - Normodyne, also sold as Trandate
    • Metoprolol - Lopressor, also sold as Toprol
    • Nadolol - Corgard
    • Penbutolol - Levatol
    • Propranolol - Inderal, Inderal LA
    • Timolol - Blocadren

    Calcium Channel Blockers

    Calcium channel blockers can reduce blood pressure by dilating the arteries and, in some cases, reducing the force of the heart's contractions.

    • Amlodipine - Norvasc, also sold as Caduet and Lotrel
    • Diltiazem - Cardizem, also sold as Dilacor and Tiazac
    • Felodipine - Plendil
    • Isradipine - DynaCirc
    • Nicardipine - Cardene
    • Nifedipine - Procardia XL, also sold as Adalat
    • Nisoldipine - Sular
    • Verapamil hydrochloride - Isoptin, also sold as Calan, Verelan, and Covera

    Angiotensin Converting Enzyme Inhibitors

    The angiotensin converting enzyme inhibitors (the "ACE inhibitors") can lower blood pressure by dilating the arteries.

    • Benazepril - Lotensin
    • Captopril - Capoten
    • Enalapril - Vasotec, also sold as Vaseretic
    • Fosinopril - Monopril
    • Lisinopril - Prinivil, also sold as Zestril
    • Moexipril - Univasc
    • Quinapril - Accupril
    • Ramipril - Altace
    • Trandolapril - Mavik

    Angiotensin II Receptor Blockers

    The angiotensin II receptor blockers (the "ARBs") also reduce blood pressure by dilating the arteries.

    • Candesartan - Atacand
    • Irbesartan - Avapro
    • Losartan - Cozaar
    • Telmisartan - Micardis
    • Valsartan - Diovan

    Other, Less Commonly Used Hypertension Drugs

    • Clonidine - Catapres
    • Doxazosin - Cardura
    • Guanabenz - Wytensin
    • Guanfacine - Tenex
    • Hydralazine hydrochloride - Apresoline
    • Methyldopa - Aldomet
    • Prazosin - Minipress
    • Reserpine - Serpasil
    • Terazosin - Hytrin

    Combination Drugs for Hypertension

    Numerous combination drugs have been marketed for hypertension, and it is almost impossible to keep track of new ones that come along, or old ones that fade away. The following is a reasonably complete list of the most commonly prescribed combination drugs used for hypertension.

    • Amiloride and hydrochlorothiazide - Moduretic
    • Amlodipine and benazepril - Lotrel
    • Atenolol and chlorthalidone - Tenoretic
    • Benazepril and hydrochlorothiazide - Lotensin HCT
    • Bisoprolol and hydrochlorothiazide - Ziac
    • Captopril and hydrochlorothiazide - Capozide
    • Enalapril and hydrochlorothiazide - Vaseretic
    • Felodipine and enalapril - Lexxel
    • Hydralazine and hydrochlorothiazide - Apresazide
    • Lisinopril and hydrochlorothiazide - Prinzide, also sold as Zestoretic
    • Losartan and hydrochlorothiazide - Hyzaar
    • Methyldopa and hydrochlorothiazide - Aldoril
    • Metoprolol and hydrochlorothiazide - Lopressor HCT
    • Nadolol and bendroflumethiazide - Corzide
    • Propranolol and hydrochlorothiazide - Inderide
    • Spironolactone and hydrochlorothiazide - Aldactazide
    • Triamterene and hydrochlorothiazide - Dyazide, also sold as Maxide
    • Verapamil extended release) and trandolapril - Tarka

    A Word From Verywell

    Hypertension is an extremely common medical problem that can have severe consequences if it is not treated adequately. However, with so many treatment options, you should expect your doctor to find a therapeutic regimen that will greatly decrease your risk of a bad outcome from hypertension, without disrupting your everyday life.

    Sources:

    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.

    Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the Management of Arterial Hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2013; 31:1281.

    Weber MA, Schiffrin EL, White WB, et al. Clinical Practice Guidelines for the Management of Hypertension in the Community a Statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens 2014; 32:3.

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