Hypertension monotherapy

Hypertension (monotherapy) PO Initially, 5-lOmg/day. Range 20-40 mg/day. Hypertension (combination therapy) PO Discontinue diuretic 2-3 days prior to initiating benazepril, then dose as noted above. If unable to discontinue diuretic, begin benazepril at 5 mg/day. 

In the treatment of hypertension, ACE inhibitors are as effective as diuretics, (3-adrenoceptor antagonists, or calcium channel blockers in lowering blood pressure. However, increased survival rates have only been demonstrated for diuretics and (3-adrenoceptor antagonists. ACE inhibitors are approved for monotherapy as well as for combinational regimes. ACE inhibitors are the dtugs of choice for the treatment of hypertension with renal diseases, particularly diabetic nephropathy, because they prevent the progression of renal failure and improve proteinuria more efficiently than the other diugs. 

Two types of diuretics are used for volume management in HF thiazides and loop diuretics. Thiazide diuretics such as hydrochlorothiazide, chlorthalidone, and metolazone block sodium and chloride reabsorption in the distal convoluted tubule. Thiazides are weaker than loop diuretics in terms of effecting an increase in urine output and therefore are not utilized frequently as monotherapy in HF. They are optimally suited for patients with hypertension who have mild congestion. Additionally, the action of thiazides is limited in patients with renal insufficiency (creatinine clearance less than 30 mL/minute) due to reduced secretion into their site of action. An exception is metolazone, which retains its potent action in patients with renal dysfunction. Metolazone is often used in combination with loop diuretics when patients exhibit diuretic resistance, defined as edema unresponsive to loop diuretics alone. 

Rasilez contains aliskiren, which is a renin inhibitor used in hypertension as monotherapy or in combination with other antihypertensives. It is to be used with caution in patients taking concomitant diuretics, on a low-sodium diet or who are dehydrated and in patients with a glomerular filtration rate less than 30 mL/minute. Aliskiren may cause diarrhoea as a side-effect and it should be administered with or after food. It exists in two dosage strengths, 150 mg and 300 mg. 

In instituting single-drug therapy (monotherapy), the following considerations apply 3-blockers (p. 92) are of value in the treatment of juvenile hypertension with tachycardia and high cardiac output however, in patients disposed to bronchospasm, even 3i-se-lective blockers are contraindicated. 

Angiotensin-converting enzyme inhibitors have turned out to be very effective antihypertensive drugs that have begun to overtake )3-adrenoblockers, especially in monotherapy of hypertension. 

Hypertension The usual initial monotherapy dose is 80 mg 3 times/day (240 mg/day). Daily dosages of 360 and 480 mg have been used, but there is no evidence that dosages more than 360 mg provide added effect. 

Initial drug therapy is monotherapy for Stage 1 and Stage 2 hypertension. Preferred because a reduction in morbidity and mortality has been demonstrated. 

Hypertension - Administer with or without food. The usual recommended starting dose is 16 mg once daily when used as monotherapy in patients who are not volume-depleted. Candesartan can be administered once or twice daily with total daily doses ranging from 8 to 32 mg. Most of the antihypertensive effect is present within 2 weeks maximal blood pressure reduction generally is obtained within 4 to 6 weeks of treatment. 

Beta-blockers can no longer be considered as first line monotherapy for uncomplicated hypertension in older patients since some studies suggest they are less effective than diuretics and no better than placebo in reducing cardiovascular outcomes. Their use in elderly with hypertension probably should be confined to those with other indications such as angina, following myocardial infarction or with heart failure. 

Potassium-sparing diuretics, such as amiloride and triamterene. These agents reduce at the tubular level the reabsorption of sodium and water, whereas the excretion of potassium is diminished. Their primary effects are independent of aldosterone. They are slow-acting and weak diuretics, which are unsuitable as monotherapy of hypertension or heart failure. For this reason, they are always combined with thiazide or loop diuretics. Several combined preparations are commercially available. 

Parra D, Lnndy AL, Bierman B. Alpha-blocker monotherapy and anticipated occurrences of heart failure in hypertensive veterans. Am J Hypertens 2005 18 573-5. 

When drugs from the main available classes are used as monotherapy at the recommended doses, they produce very similar BP reductions. In general, the sizes of the BP reductions increase with the initial level of BP, but typically the placebo-adjusted reductions average about 4-8% for both SBP-DBP. Thus, for patients with blood pressures of about 160/95 mmHg, the usual reduction produced by monotherapy would be about 7-13 mmHg systolic and 4-8 mmHg diastolic. Clearly, for many patients with hypertension, such reductions in BP would not restore optimal or even nonhypertensive blood pressure levels. 

C. Although still highly controversial, the initial use of a thiazide diuretic for monotherapy has been recommended by the Joint National Committee on Detection, Evaluation and treatment of High Blood Pressure. Triamterene and Aldactone are rarely used alone and exhibit no antihypertensive activity. A recent study found that the loop diuretics bumetanide and furosemide effectively reduced blood pressure. Serum lipid levels were less affected than with thiazide diuretics or chlorthalidone. However, thiazide diuretics are a more conservative and approved approach for the initial treatment of hypertension that avoid the more dramatic fluid and electrolyte shifts that occur with loop diuretics. 

Monotherapy of hypertension (treatment with a single drug) is desirable because compliance is likely to be better and cost is lower, and because in some cases adverse effects are fewer. However, most patients with hypertension require two or more drugs, preferably acting by different mechanisms (polypharmacy). According to some estimates, up to 40% of patients may respond inadequately even to two agents and are considered to have "resistant hypertension." Some of these patients have treatable secondary hypertension that has been missed but most do not and three or more drugs are required. 

Changes from baseline blood pressure and plasma renin activity in patients with diabetes and hypertension receiving aliskiren monotherapy (150 mg/d), ramipril monotherapy (5 mg/d) or the combination of aliskiren (50 mg/d) and ramipril (5 mg/d). 

The first use of lithium for therapeutic purposes began in the mid-19th century to treat gout. Lithium had a relatively brief period of use as a substitute for sodium chloride in hypertensive patients in the 1940s, but it proved too toxic when available without monitoring and was banned. In 1949, Cade discovered that lithium was an effective treatment for bipolar disorder, engendering a series of controlled trials which confirmed its efficacy as monotherapy for the manic phase of bipolar disorder. 

STEP 1 In patients with mild hypertension, drug therapy is usually initiated with a single agent (monotherapy) from one of the following classes a diuretic, a beta blocker, an angiotensin converting enzyme (ACE) inhibitor, or a calcium channel blocker. 

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