Don't wait. Get your hypertensive
patients started on two firstline meds as soon as you
diagnose them, urge new recommendations from the Canadian
Hypertension Education Program (CHEP). The guidelines
appear in the June issue of the Canadian Journal
"Most patients are going to need
two drugs anyway," says guideline author Dr Norm Campbell,
a hypertension specialist at the University of Calgary.
"You can get there by whacking them on right away, or
gradual intensification of therapy the old way.
The upside of initiating with two drugs is that the
response is more predictable and greater, and patient
adherence and satisfaction is better." This is especially
true when they're started on a single tablet combining
the two drugs.
The recommendation which
is for patients whose systolic BP is 20mmHg or more
above target, or whose diastolic BP is at least 10mmHg
above target doesn't suggest any specific drug
combinations. Dr Campbell says the best route is "two
firstline drugs that are known to work well together."
He says doctors should avoid prescribing combinations
like an ACE inhibitor plus an angiotensin receptor blocker
(ARB) or beta-blocker, as these wouldn't work very well.
The combo approach should be avoided in patients who
are susceptible to hypotension, adds Dr Campbell.
The new guidelines also argue for
increased use of home BP measurement for patients. Dr
Campbell says over half of the patients at his specialized
clinic take home BP readings and he says it's been fantastic
for reinforcing medication compliance. "This can rule
out white coat and masked hypertension and identify
patients who need fewer medications." He says $100 can
get your patient a decent machine (the CHEP website
has a list of approved devices).
The guidelines also strongly urge
you to give your patients written materials on hypertension.
Patient handouts are available for download at http://hypertension.ca/chep/
(under Resource Centre > Info for Patients) or by