JULY 2008


Start two-med combo for high BP now

Don't wait for 'step-up' approach to kick in: new guidelines

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 of Cardiology.

"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 emailing [email protected].



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