Antihypertensive drug: Difference between revisions

Line 30:

** [[eplerenone]]

In the United States, the JNC8 (Eighth Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) recommends thiazide-type diuretics to be one of the first-line drug treatments for hypertension, either as monotherapy or in combination with [[calcium channel blockers]], [[ACE inhibitors]], or [[angiotensin II receptor antagonists]].~~<ref name=JNC8 />~~ There are fixed-dose [[combination drugs]], such as [[ACE inhibitor and thiazide combination]]s. Despite thiazides being cheap and effective, they are not prescribed as often as some newer drugs. This is because they have been associated with increased risk of new-onset diabetes and as such are recommended for use in patients over 65, for whom the risk of new-onset diabetes is outweighed by the benefits of controlling systolic blood pressure. Another theory is that they are off-patent and thus rarely promoted by the drug industry.

In the United States, the JNC8 (Eighth Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) recommends thiazide-type diuretics to be one of the first-line drug treatments for hypertension, either as monotherapy or in combination with [[calcium channel blockers]], [[ACE inhibitors]], or [[angiotensin II receptor antagonists]]. There are fixed-dose [[combination drugs]], such as [[ACE inhibitor and thiazide combination]]s. Despite thiazides being cheap and effective, they are not prescribed as often as some newer drugs. This is because they have been associated with increased risk of new-onset diabetes and as such are recommended for use in patients over 65, for whom the risk of new-onset diabetes is outweighed by the benefits of controlling systolic blood pressure. Another theory is that they are off-patent and thus rarely promoted by the drug industry.

Medications that are classified as potassium-sparing diuretics which block the epithelial sodium channel (ENaC), such as [[amiloride]] and [[triamterene]], are seldom prescribed as monotherapy. ENaC blocker medications need stronger public evidence for their blood pressure reducing effect.

Line 71:

* [[trandolapril]]

* [[benazepril]]

A systematic review of 63 trials with over 35,000 participants indicated ACE inhibitors significantly reduced doubling of serum creatinine levels compared to other drugs (ARBs, α blockers, β blockers, etc.), and the authors suggested this as a first line of defense.~~<ref name = "wu" />~~ The AASK trial showed that ACE inhibitors are more effective at slowing down the decline of [[kidney function]] compared to [[calcium channel blockers]] and [[beta blockers]]. As such, ACE inhibitors should be the drug treatment of choice for patients with [[chronic kidney disease]] regardless of race or diabetic status.

A systematic review of 63 trials with over 35,000 participants indicated ACE inhibitors significantly reduced doubling of serum creatinine levels compared to other drugs (ARBs, α blockers, β blockers, etc.), and the authors suggested this as a first line of defense. The AASK trial showed that ACE inhibitors are more effective at slowing down the decline of [[kidney function]] compared to [[calcium channel blockers]] and [[beta blockers]]. As such, ACE inhibitors should be the drug treatment of choice for patients with [[chronic kidney disease]] regardless of race or diabetic status.

However, ACE inhibitors (and angiotensin II receptor antagonists) should not be a first-line treatment for black hypertensives without [[chronic kidney disease]].~~<ref name=JNC8 />~~ Results from the [[Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial|ALLHAT]] trial showed that [[thiazide]]-type diuretics and calcium channel blockers were both more effective as monotherapy in improving cardiovascular outcomes compared to ACE inhibitors for this subgroup.~~<ref name=allhat />~~ Furthermore, ACE inhibitors were less effective in reducing blood pressure and had a 51% higher risk of stroke in black hypertensives when used as initial therapy compared to a calcium channel blocker. There are fixed-dose [[combination drugs]], such as [[ACE inhibitor and thiazide combination]]s.

However, ACE inhibitors (and angiotensin II receptor antagonists) should not be a first-line treatment for black hypertensives without [[chronic kidney disease]]. Results from the [[Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial|ALLHAT]] trial showed that [[thiazide]]-type diuretics and calcium channel blockers were both more effective as monotherapy in improving cardiovascular outcomes compared to ACE inhibitors for this subgroup. Furthermore, ACE inhibitors were less effective in reducing blood pressure and had a 51% higher risk of stroke in black hypertensives when used as initial therapy compared to a calcium channel blocker. There are fixed-dose [[combination drugs]], such as [[ACE inhibitor and thiazide combination]]s.

Notable side effects of ACE inhibitors include [[dry cough]], [[hyperkalemia|high blood levels of potassium]], fatigue, dizziness, headaches, loss of taste and a risk for [[angioedema]].

Line 133:

** [[clonidine]] (indirectly)

Although [[beta blocker]]s lower blood pressure, they do not have a positive benefit on endpoints as some other antihypertensives. In particular, beta-blockers are no longer recommended as first-line treatment due to relative adverse risk of stroke and new-onset of type 2 diabetes when compared to other medications,~~<ref name=nps02 />~~ while certain specific beta-blockers such as [[atenolol]] appear to be less useful in overall treatment of hypertension than several other agents. A systematic review of 63 trials with over 35,000 participants indicated β-blockers increased the risk of mortality, compared to other antihypertensive therapies. They do, however, have an important role in the prevention of heart attacks in people who have already had a heart attack. In the United Kingdom, the June 2006 "Hypertension: Management of Hypertension in Adults in Primary Care" guideline of the [[National Institute for Health and Clinical Excellence]], downgraded the role of beta-blockers due to their risk of provoking [[type 2 diabetes]].

Although [[beta blocker]]s lower blood pressure, they do not have a positive benefit on endpoints as some other antihypertensives. In particular, beta-blockers are no longer recommended as first-line treatment due to relative adverse risk of stroke and new-onset of type 2 diabetes when compared to other medications, while certain specific beta-blockers such as [[atenolol]] appear to be less useful in overall treatment of hypertension than several other agents. A systematic review of 63 trials with over 35,000 participants indicated β-blockers increased the risk of mortality, compared to other antihypertensive therapies. They do, however, have an important role in the prevention of heart attacks in people who have already had a heart attack. In the United Kingdom, the June 2006 "Hypertension: Management of Hypertension in Adults in Primary Care" guideline of the [[National Institute for Health and Clinical Excellence]], downgraded the role of beta-blockers due to their risk of provoking [[type 2 diabetes]].

Despite lowering blood pressure, [[alpha blocker]]s have significantly poorer endpoint outcomes than other antihypertensives, and are no longer recommended as a first-line choice in the treatment of hypertension.

Line 141:

[[Vasodilator]]s act directly on the [[smooth muscle]] of arteries to relax their walls so blood can move more easily through them; they are only used in [[hypertensive emergency|hypertensive emergencies]] or when other drugs have failed, and even so are rarely given alone.{{cn|date=March 2023}}

[[Sodium nitroprusside]], a very potent, short-acting vasodilator, is most commonly used for the quick, temporary reduction of blood pressure in emergencies (such as [[malignant hypertension]] or [[aortic dissection]]).[[Hydralazine]] and its derivatives are also used in the treatment of severe hypertension, although they should be avoided in emergencies.~~<ref name=Varon/>~~ They are no longer indicated as first-line therapy for high blood pressure due to side effects and safety concerns, but hydralazine remains a drug of choice in [[gestational hypertension]].

[[Sodium nitroprusside]], a very potent, short-acting vasodilator, is most commonly used for the quick, temporary reduction of blood pressure in emergencies (such as [[malignant hypertension]] or [[aortic dissection]]).[[Hydralazine]] and its derivatives are also used in the treatment of severe hypertension, although they should be avoided in emergencies. They are no longer indicated as first-line therapy for high blood pressure due to side effects and safety concerns, but hydralazine remains a drug of choice in [[gestational hypertension]].

==Renin inhibitors==

@@ Line 30: / Line 30: @@
 ** [[eplerenone]]
-In the United States, the JNC8 (Eighth Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) recommends thiazide-type diuretics to be one of the first-line drug treatments for hypertension, either as monotherapy or in combination with [[calcium channel blockers]], [[ACE inhibitors]], or  [[angiotensin II receptor antagonists]].<ref name=JNC8 /> There are fixed-dose [[combination drugs]], such as [[ACE inhibitor and thiazide combination]]s. Despite thiazides being cheap and effective, they are not prescribed as often as some newer drugs. This is because they have been associated with increased risk of new-onset diabetes and as such are recommended for use in patients over 65, for whom the risk of new-onset diabetes is outweighed by the benefits of controlling systolic blood pressure. Another theory is that they are off-patent and thus rarely promoted by the drug industry.
+In the United States, the JNC8 (Eighth Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) recommends thiazide-type diuretics to be one of the first-line drug treatments for hypertension, either as monotherapy or in combination with [[calcium channel blockers]], [[ACE inhibitors]], or  [[angiotensin II receptor antagonists]]. There are fixed-dose [[combination drugs]], such as [[ACE inhibitor and thiazide combination]]s. Despite thiazides being cheap and effective, they are not prescribed as often as some newer drugs. This is because they have been associated with increased risk of new-onset diabetes and as such are recommended for use in patients over 65, for whom the risk of new-onset diabetes is outweighed by the benefits of controlling systolic blood pressure. Another theory is that they are off-patent and thus rarely promoted by the drug industry.
 Medications that are classified as potassium-sparing diuretics which block the epithelial sodium channel (ENaC), such as [[amiloride]] and [[triamterene]], are seldom prescribed as monotherapy. ENaC blocker medications need stronger public evidence for their blood pressure reducing effect.
@@ Line 71: / Line 71: @@
 * [[trandolapril]]
 * [[benazepril]]
-A systematic review of 63 trials with over 35,000 participants indicated ACE inhibitors significantly reduced doubling of serum creatinine levels compared to other drugs (ARBs, α blockers, β blockers, etc.), and the authors suggested this as a first line of defense.<ref name = "wu" /> The AASK trial showed that ACE inhibitors are more effective at slowing down the decline of [[kidney function]] compared to [[calcium channel blockers]] and [[beta blockers]]. As such, ACE inhibitors should be the drug treatment of choice for patients with [[chronic kidney disease]] regardless of race or diabetic status.
+A systematic review of 63 trials with over 35,000 participants indicated ACE inhibitors significantly reduced doubling of serum creatinine levels compared to other drugs (ARBs, α blockers, β blockers, etc.), and the authors suggested this as a first line of defense. The AASK trial showed that ACE inhibitors are more effective at slowing down the decline of [[kidney function]] compared to [[calcium channel blockers]] and [[beta blockers]]. As such, ACE inhibitors should be the drug treatment of choice for patients with [[chronic kidney disease]] regardless of race or diabetic status.
-However, ACE inhibitors (and angiotensin II receptor antagonists) should not be a first-line treatment for black hypertensives without [[chronic kidney disease]].<ref name=JNC8 /> Results from the [[Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial|ALLHAT]] trial showed that [[thiazide]]-type diuretics and calcium channel blockers were both more effective as monotherapy in improving cardiovascular outcomes compared to ACE inhibitors for this subgroup.<ref name=allhat /> Furthermore, ACE inhibitors were less effective in reducing blood pressure and had a 51% higher risk of stroke in black hypertensives when used as initial therapy compared to a calcium channel blocker. There are fixed-dose [[combination drugs]], such as [[ACE inhibitor and thiazide combination]]s.
+However, ACE inhibitors (and angiotensin II receptor antagonists) should not be a first-line treatment for black hypertensives without [[chronic kidney disease]]. Results from the [[Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial|ALLHAT]] trial showed that [[thiazide]]-type diuretics and calcium channel blockers were both more effective as monotherapy in improving cardiovascular outcomes compared to ACE inhibitors for this subgroup. Furthermore, ACE inhibitors were less effective in reducing blood pressure and had a 51% higher risk of stroke in black hypertensives when used as initial therapy compared to a calcium channel blocker. There are fixed-dose [[combination drugs]], such as [[ACE inhibitor and thiazide combination]]s.
 Notable side effects of ACE inhibitors include [[dry cough]], [[hyperkalemia|high blood levels of potassium]], fatigue, dizziness, headaches, loss of taste and a risk for [[angioedema]].
@@ Line 133: / Line 133: @@
 ** [[clonidine]] (indirectly)
-Although [[beta blocker]]s lower blood pressure, they do not have a positive benefit on endpoints as some other antihypertensives. In particular, beta-blockers are no longer recommended as first-line treatment due to relative adverse risk of stroke and new-onset of type 2 diabetes when compared to other medications,<ref name=nps02 /> while certain specific beta-blockers such as [[atenolol]] appear to be less useful in overall treatment of hypertension than several other agents. A systematic review of 63 trials with over 35,000 participants indicated β-blockers increased the risk of mortality, compared to other antihypertensive therapies. They do, however, have an important role in the prevention of heart attacks in people who have already had a heart attack. In the United Kingdom, the June 2006 "Hypertension: Management of Hypertension in Adults in Primary Care" guideline of the [[National Institute for Health and Clinical Excellence]], downgraded the role of beta-blockers due to their risk of provoking [[type 2 diabetes]].
+Although [[beta blocker]]s lower blood pressure, they do not have a positive benefit on endpoints as some other antihypertensives. In particular, beta-blockers are no longer recommended as first-line treatment due to relative adverse risk of stroke and new-onset of type 2 diabetes when compared to other medications, while certain specific beta-blockers such as [[atenolol]] appear to be less useful in overall treatment of hypertension than several other agents. A systematic review of 63 trials with over 35,000 participants indicated β-blockers increased the risk of mortality, compared to other antihypertensive therapies. They do, however, have an important role in the prevention of heart attacks in people who have already had a heart attack. In the United Kingdom, the June 2006 "Hypertension: Management of Hypertension in Adults in Primary Care" guideline of the [[National Institute for Health and Clinical Excellence]], downgraded the role of beta-blockers due to their risk of provoking [[type 2 diabetes]].
 Despite lowering blood pressure, [[alpha blocker]]s have significantly poorer endpoint outcomes than other antihypertensives, and are no longer recommended as a first-line choice in the treatment of hypertension.
@@ Line 141: / Line 141: @@
 [[Vasodilator]]s act directly on the [[smooth muscle]] of arteries to relax their walls so blood can move more easily through them; they are only used in [[hypertensive emergency|hypertensive emergencies]] or when other drugs have failed, and even so are rarely given alone.{{cn|date=March 2023}}
-[[Sodium nitroprusside]], a very potent, short-acting vasodilator, is most commonly used for the quick, temporary reduction of blood pressure in emergencies (such as [[malignant hypertension]] or [[aortic dissection]]).[[Hydralazine]] and its derivatives are also used in the treatment of severe hypertension, although they should be avoided in emergencies.<ref name=Varon/> They are no longer indicated as first-line therapy for high blood pressure due to side effects and safety concerns, but hydralazine remains a drug of choice in [[gestational hypertension]].
+[[Sodium nitroprusside]], a very potent, short-acting vasodilator, is most commonly used for the quick, temporary reduction of blood pressure in emergencies (such as [[malignant hypertension]] or [[aortic dissection]]).[[Hydralazine]] and its derivatives are also used in the treatment of severe hypertension, although they should be avoided in emergencies. They are no longer indicated as first-line therapy for high blood pressure due to side effects and safety concerns, but hydralazine remains a drug of choice in [[gestational hypertension]].
 ==Renin inhibitors==