Select Page

Hypertension

Jul 25, 2019

Hypertension is defined as blood pressure more than 140/90 mmHg (for patients less than 60 years old) and more than 150/90 mmHg (for patients more than 60 years old). For patients with renal insufficiency BP more than 130/80 mmHg should be treated.

Medications:

Monotherapy (please choose one of the following):

For patient age less than 60 years – tab. Telmikind 20 (Telmisartan 20 mg) 1 tablet in the morning. Gradually increase the dose by 20 mg till maximum dose of 80 mg per day. This is the preferred choice for diabetics.

For patient age more than 60 years with isolated systolic hypertension, diabetes, angina, hyperlipidaemia, decide as per pulse rate:

  • Pulse rate less than 80/minute – tab. Amlokind 2.5 (Amlodipine 2.5 mg) 1 tablet once a day. Gradually increase the dose by 2.5 mg steps till maximum dose of 10 mg per day. Amlodipine is contraindicated in peripheral vascular disease, heart block, congestive heart failure, peptic ulcer disease and peripheral oedema.
  • If pulse rate is more than 80/minute – start tab. Cilaheart 5 (Cilnidipine 5 mg) 1 tablet a day. Gradually increase the dose by 5 mg steps till maximum dose of 20 mg per day.
  • For patient age more than 60 years with cardiac failure – start tab. CTD 6.25 mg (Chlorthalidone 6.25 mg) 1 tablet in the morning. Gradually increase this by 6.25 mg till maximum dose of 100 mg per day (contraindicated in diabetes, gout, dyslipidemia, sulfonamide allergy, benign hypertrophy of prostate).

Dual therapy is considered when monotherapy fails to control blood pressure:

In such a case choose one of the following combinations:

  • Tab. Telmikind 20 (Telmisartan 20 mg) 1 tablet daily (adjust the dose till maximum of 80 mg per day) + tab. Amlokind 2.5 (Amlodipine 2.5 mg) 1 tablet daily (adjust the dose till maximum of 10 mg per day).
  • Tab. Telmikind 20 (Telmisartan 20 mg) 1 tablet daily (adjust the dose till maximum of 80 mg per day) + tab. CTD 6.25 (Chlorthalidone 6.25 mg) 1 tablet in the morning (adjust the dose till maximum of 100 mg per day).
  • Tab. CTD 6.25 (Chlorthalidone 6.25 mg) 1 tablet in the morning (adjust the dose till maximum of 100 mg per day) + tab. Nebi 2.5 (Nebivolol 2.5 mg) 1 tablet once a day (adjust the dose till maximum of 40 mg per day).

Note – do not use beta blockers as a monotherapy or in COPD, asthma or depression.

Triple therapy is reserved for resistant cases:

  • Tab. Telmikind 20 (Telmisartan 20 mg) 1 tablet daily + tab. Amlokind 2.5 (Amlodipine 2.5 mg) 1 tablet daily + tab. CTD 6.25 (Chlorthalidone 6.25 mg) 1 tablet once a day with breakfast. The dose of this combination can be increased to maximum dose as mentioned above.

Guidance for selecting the correct treatment:

  • Prehypertension (BP 120/80 – 140/90 mmHg) – advise lifestyle modification for 2 months and then start monotherapy if needed.
  • Stage 1 (BP 140/90 – 160/100 mmHg) – lifestyle modification and monotherapy
  • Stage 2 (BP 160/100 – 180/110 mmHg) – lifestyle modification and dual therapy straightaway
  • Stage 3 (BP more than 180/110 mmHg) and no end organ damage – treat as stage 2 hypertension with close and frequent follow ups.
  • Stage 4 hypertensive emergency (BP more than 180/110 mmHg) with end organ damage – refer to secondary care.

Treatment options based on patient population and co-morbities:

Age less than 60 years

  • Step 1 – Tab. Telmikind (Telmisartan)
  • Step 2 – Tab. Amlokind (Amlodipine)
  • Step 3 – Tab. CTD (Chlorthalidone)

Age more than 60 years

  • Step 1 – Tab. CTD (Chlorthalidone)
  • Step 2 – Tab. Amlokind (Amlodipine)
  • Step 3 – Tab. Telmikind (Telmisartan)

For patients with diabetes

  • Step 1 – Tab. Telmikind (Telmisartan)
  • Step 2 – Tab. CTD (Chlorthalidone)
  • Step 3 – Tab. Amlokind (Amlodipine)

For patients with congestive heart failure

  • Step 1– Tab. Telmikind (Telmisartan)
  • Step 2 – Tab. Carvistar (Carvedilol)
  • Step 3 – Add tab. Aldactone (Spironolactone)

For patients with coronary artery disease

  • Step 1 – Tab. Nebi (Nebivolol)
  • Step 2 – Tab. Telmikind (Telmisartan)
  • Step 3 – Tab. CTD (Chlorthalidone)

For patients with chronic renal disease

  • Step 1 – Tab. Telmikind (Telmisartan)
  • Step 2 – Tab. CTD (Chlorthalidone)

For patients with left ventricular hypertrophy

  • Step 1 – Tab. Telmikind (Telmisartan)
  • Step 2 – Tab. CTD (Chlorthalidone)
  • Step 3 – Tab. Amlokind (Amlodipine) – if no systolic dysfunction

For patients with angina – Tab. Nebi (Nebivolol).

For patients with atrial tachycardia or fibrillation – Tab. Ivabrad 5 (Ivabradine 5 mg) twice a day with meals. Gradually increase till maximum dose is 7.5 mg twice a day.

For patients with peripheral vascular disease – Tab. Ramistar 2.5 (Ramipril 2.5 mg) once a day.

General advice:

  • Diet – plenty of vegetables, fruits and low-fat dairy products, as well as whole grains, fish, poultry and nuts.
  • Regular isometric exercises.

Investigations:

  • Lipid profile – high cholesterol needs to be treated.
  • Fasting blood glucose – to rule out diabetes.
  • Serum electrolytes – to monitor the treatment with diuretics.
  • Urine routine, BUN and serum creatinine – to rule out proteinuria and presence of renal impairment.
  • ECG – to rule out  coronary iscahemia, left ventricular hypertrophy
  • echo cardiogram- to rule out ventricular hypertrophy, valvular abnormalities
  • Ultrasound scan of abdomen – to rule out  renal diseases
  • TSH – to rule out hypo or hyperthyroidism.
  • 24-hour urine cortisol – to rule out Cushing’s Syndrome in case of secondary hypertension.

Referral:

Consider referral to MD physician or equivalent in case of uncontrolled hypertension or hypertensive end organ damage.