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Hypertension

Updated : January 31, 2024





Background

Hypertension is characterized by a systolic blood pressure of 130 mmHg or a diastolic blood pressure of 80 mmHg. One of the most prevalent chronic conditions, hypertension, is defined by a continuous rise in arterial pressure.

One of the most significant comorbidities influencing the emergence of stroke, myocardial infarction, heart failure, and renal failure, hypertension has been one of the most researched subjects of the past century.

There is consensus that persistent blood pressure readings of 140/90mmHg or above should be treated with the conventional therapeutic aim of 130/80mmHg or less. The definition and classifications of hypertension have been developing throughout time.

Epidemiology

Around the world, more than a billion adults have hypertension, which impacts up to 45% of the adult population. All socioeconomic classes have significant rates of hypertension, which increase with age, reaching up to 60% over the age of 60.

Hypertension causes more cardiovascular disease-related deaths in the US than any other modifiable risk factor.

It is the second-leading preventable cause of death worldwide after cigarette smoking. Recent estimates suggest by 2025, there may be up to 1.5 billion people worldwide with hypertension, an increase of up to 15% or 20%.

Anatomy

Pathophysiology

An essential regulator of blood volume is sodium (Na+). High serum Na+ levels promote water retention, increasing blood volume and pressure. In normotensive adults, compensatory hemodynamic adjustments stabilize blood pressure as dietary Na+ increases. Nitric oxide generation from the endothelium increased, while renal and peripheral vascular resistance reduced.

However, blood pressure increases if nitric oxide’s impact is diminished or nonexistent. Endothelial dysfunction is a risk factor for the emergence of salt sensitivity and hypertension. Salt sensitivity is characterized by an increase in systolic blood pressure of at least 10 mmHg within a few hours of intake. It is defined as a considerable increase in blood pressure after a Na+ load of less than 5 g.

Renin- Angiotensin-Aldosterone System [RAAS] 

RAAS is found in multiple organs at the cellular level. However, its most essential function is to assist in regulating pressure-volume balance in the kidney, where it maintains perfusion in states of volume depletion and is inhibited in circumstances of fluid excess. The juxtaglomerular cells of the kidney produce and store renin and its precursor, pro-renin, which are then released in response to various stimuli. Renin’s primary function is to break down angiotensinogen to create angiotensin I.

The pathogenetic significance of RAAS in hypertension is centered on how the angiotensin-converting enzyme (ACE) converts angiotensin I into angiotensin II. By enhancing the function of the sodium-hydrogen exchanger, sodium-bicarbonate exchanger, and sodium-potassium ATPase, as well as promoting aldosterone production and release from the adrenal glomerulosa, angiotensin II improves Na+ reabsorption in the proximal tubule.

Angiotensin II is also associated with endothelial dysfunction and causes renal, cardiac, and vascular damage. These effects are pro-fibrotic and pro-inflammatory and are mediated mainly by increased oxidative stress. Angiotensin II is strongly aligned to target organ damage in hypertension through these processes. Aldosterone plays a significant role in hypertension by binding to the mineralocorticoid receptor and inducing non-genomic effects.

These effects include activating the amiloride-sensitive sodium channel, also known as the epithelial sodium channel, which stimulates renal Na+ reabsorption in the cortical collecting duct. Additionally, aldosterone has a wide range of non-epithelial actions that support hypertension, vasoconstriction, and endothelial dysfunction. These include vascular fibrosis, extracellular matrix deposition, vascular remodeling, vascular smooth muscle cell proliferation, and elevated oxidative stress.

Etiology

Idiopathic or essential hypertension is the most common type of hypertension. It has been hypothesized that consuming more salt increases the potential risk of hypertension.

The patient’s genetic ability for a salt response is identified as one of the elements contributing to the development of hypertension. Salt sensitivity affects 50 to 60 % of the patients, who are more likely to develop hypertension.

Genetics

Prognostic Factors

The prognosis depends on blood pressure control and is positive if blood pressure is well controlled; nevertheless, as hypertension is a progressive condition, complications may occur in a few patients.

Adequate lifestyle and management measures accomplish little more to delay the onset and progression of complications like chronic kidney disease and renal failure.

Clinical History

Physical Examination

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment paradigm for hypertension (high blood pressure) typically involves a combination of lifestyle modifications and pharmaceutical interventions. Here is an overview of the treatment paradigm for hypertension:

Lifestyle Modifications:

Dietary changes: Encourage a balanced diet rich in fruits, vegetables, whole grains, and low-fat dairy products. Emphasize the importance of reducing sodium (salt) intake and limiting alcohol consumption.

Regular exercise: Recommend at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, along with muscle-strengthening activities at least twice a week.

Weight management: Promote weight loss for overweight or obese individuals to achieve a healthy body weight, as excess weight contributes to increased blood pressure.

Sodium restriction: Encourage reducing sodium intake to less than 2,300 milligrams per day (and even lower for certain populations, such as those with diabetes or kidney disease).

Limit alcohol consumption: Advise moderate alcohol consumption (up to one drink per day for women and up to two drinks per day for men) or complete abstinence if recommended by a healthcare provider.

Pharmaceutical Interventions:

Stepwise medication approach: Initiate antihypertensive medication based on the individual’s blood pressure levels, comorbidities, and risk factors.

First-line medications: Typically, thiazide diuretics (e.g., hydrochlorothiazide) or ACE inhibitors (e.g., lisinopril) are recommended as initial therapy due to their effectiveness, safety profile, and cost.

Combination therapy: If blood pressure goals are not achieved with a single medication, combination therapy with two or more antihypertensive agents from different drug classes may be prescribed.

Medication adherence: Emphasize the importance of taking medications as prescribed and educate patients about potential side effects and drug interactions.

Regular blood pressure monitoring: Encourage patients to monitor their blood pressure regularly at home and provide feedback to their healthcare provider.

Ongoing Management and Monitoring:

Follow-up visits: Schedule regular follow-up visits to monitor blood pressure, assess medication effectiveness and potential side effects, and adjust treatment as necessary.

Risk factor management: Address and manage other cardiovascular risk factors, such as diabetes, dyslipidemia (abnormal lipid levels), and smoking cessation.

Patient education: Provide comprehensive education on hypertension, its risks, and the importance of lifestyle modifications and medication adherence.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Healthy Food Environments

Promote healthier food choices: Collaborate with food manufacturers, restaurants, and cafeterias to provide and promote low-sodium options, reduce the availability of high-sodium processed foods, and clearly label nutritional information.

Smoke-Free Environments

Creating smoke-free environments is crucial for individuals with hypertension, as exposure to tobacco smoke can significantly increase the risk of cardiovascular problems. Here are some speciality-wise suggestions for establishing smoke-free environments:

Healthcare facilities: Implement strict no-smoking policies in hospitals, clinics, and other healthcare settings. Provide designated outdoor smoking areas away from entrances and windows.

Public spaces: Advocate for smoke-free policies in public areas such as parks, playgrounds, and outdoor recreational areas to protect individuals, especially children, from secondhand smoke.

Educational campaigns: Collaborate with schools, community centers, and workplaces to raise awareness about the dangers of smoking and the importance of smoke-free environments.

Smoking cessation programs: Offer comprehensive smoking cessation programs that include counseling, support groups, and access to medication to assist individuals in quitting smoking.

Patient education: Educate patients about the risks of smoking and secondhand smoke, emphasizing the importance of maintaining a smoke-free home and car.

Nicotine replacement therapy (NRT): Provide access to NRT products, such as nicotine patches, gum, or lozenges, to assist individuals in quitting smoking and reducing withdrawal symptoms.

ACE inhibitors in management of Hypertension

ACE inhibitors (Angiotensin-Converting Enzyme inhibitors) are a class of pharmaceutical agents commonly used for the treatment of hypertension. They work by blocking the enzyme responsible for converting angiotensin I into angiotensin II, a hormone that constricts blood vessels and increases blood pressure. By inhibiting this enzyme, ACE inhibitors help relax and widen the blood vessels, reducing blood pressure and improving blood flow.

Here are some key points about ACE inhibitors for hypertension:

  • Examples of ACE inhibitors: Lisinopril, Enalapril, Ramipril, Captopril, Perindopril, Quinapril, etc.
  • Mechanism of action: ACE inhibitors block the action of the angiotensin-converting enzyme, which prevents the production of angiotensin II. This results in vasodilation (widening of blood vessels) and reduces the release of aldosterone, a hormone that promotes fluid retention.
  • Indications: ACE inhibitors are commonly prescribed for hypertension. They are also used to manage other conditions, such as heart failure, diabetic nephropathy, and prevention of certain cardiovascular events.
  • Administration: ACE inhibitors are usually administered orally as tablets or capsules. The dosage and frequency of administration depend on the specific medication, patient’s age, kidney function, and the severity of hypertension.
  • Combination therapy: ACE inhibitors are often used in combination with other antihypertensive medications, such as diuretics or calcium channel blockers, to achieve better blood pressure control.

Calcium channel blockers used for Hypertension

Calcium channel blockers (CCBs) are a class of medications commonly used for the management of hypertension (high blood pressure). These medications work by blocking calcium channels in the smooth muscle cells of blood vessels, leading to relaxation and dilation of the vessels, which helps to lower blood pressure. Here are some important points regarding the use of CCBs for hypertension:

Types of Calcium Channel Blockers:

  • Dihydropyridine CCBs: This subclass includes medications like amlodipine, nifedipine, and felodipine. They primarily act on the blood vessels, resulting in vasodilation and lowering of blood pressure.
  • Non-dihydropyridine CCBs: Examples of these medications are verapamil and diltiazem. They have a more pronounced effect on the heart and are often used to control heart rate and rhythm in addition to their antihypertensive properties.

Use of Diuretics for Hypertension

Diuretics are commonly prescribed medications for the treatment of hypertension (high blood pressure). They work by increasing the excretion of sodium and water from the body, reducing the volume of fluid in the blood vessels, and thereby lowering blood pressure. Here are some important points to know about diuretics for hypertension:

  • Thiazide diuretics: Examples include hydrochlorothiazide, chlorthalidone, and indapamide. Thiazide diuretics are usually the first-line treatment for hypertension and are effective in reducing blood pressure.
  • Loop diuretics: Examples include furosemide and torsemide. Loop diuretics are often used in cases where thiazide diuretics are not effective or when there is impaired kidney function.
  • Potassium-sparing diuretics: Examples include spironolactone and eplerenone. These diuretics help to retain potassium while still promoting diuresis. They are often used in combination with other diuretics.
  • Effectiveness:
    • Diuretics are effective in reducing blood pressure and are often recommended as a first-line treatment for hypertension. They are particularly useful in patients with salt-sensitive hypertension, where excess sodium intake plays a significant role in elevated blood pressure.

Use of Renin-angiotensin-aldosterone system (RAAS) inhibitors for Hypertensive Chronic Kidney Disease

  • Diagnosis and staging: Nephrologists play a key role in assessing the severity of CKD and identifying the underlying cause. They determine the appropriate stage of CKD based on glomerular filtration rate (GFR) and albuminuria levels.
  • Blood pressure control: Nephrologists closely monitor blood pressure and prescribe antihypertensive medications to achieve target blood pressure goals, typically below 130/80 mmHg in patients with CKD.
  • Renin-angiotensin-aldosterone system (RAAS) inhibitors: Nephrologists often prescribe medications such as angiotensin-converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs) to slow the progression of CKD by reducing proteinuria and protecting the kidneys.
  • Fluid and electrolyte balance: Nephrologists monitor and manage electrolyte imbalances, including sodium, potassium, and phosphorus, which are important considerations when prescribing certain antihypertensive medications.

Use of Glucocorticoid Receptor Antagonists for Secondary Hypertension

Glucocorticoid receptor antagonists, also known as glucocorticoid antagonists or glucocorticoid receptor blockers, are a class of medications that can be used in the management of secondary hypertension. Secondary hypertension refers to high blood pressure caused by an underlying medical condition or medication. Here are some examples of glucocorticoid receptor antagonists that may be used in the treatment of secondary hypertension:

Mifepristone: mifepristone is primarily known as a medication used for pregnancy termination and in the management of certain hormonal disorders. However, it also acts as a glucocorticoid receptor antagonist and can be effective in treating hypertension caused by excess cortisol production (Cushing’s syndrome).

Spironolactone: spironolactone is a potassium-sparing diuretic that is commonly used to treat conditions like primary hyperaldosteronism (Conn’s syndrome), which can lead to secondary hypertension. It also acts as a glucocorticoid receptor antagonist, providing additional benefit in certain cases.

Medication

 

metoprolol

IR tablets
Initial dose:

100

mg

Orally

once a day

Maintenance dose: 100-450 mg orally once a day
ER tablets:
Initial dose: 25-100 mg orally once a day
Maintenance dose: 100-400 mg orally once a day



prazosin

Initial:

1

mg

Orally

8 - 12

hrs

Maintenance: 6-15 mg once a day or divided 2 to 3 times a day alternatively



doxazosin

1

mg

Orally

once a day

; the dose can be titrated to double the dose up to 16 mg qDay based on blood pressure response
ER: not recommended for HTN



timolol

10 - 20

mg

Orally

every 12 hrs

Maintenance: 20-40 mg once a day
Do not exceed 60 mg per day



nadolol

40 - 320

mg

Tablet

Orally

once a day



terazosin

Initial:

1

mg

Orally

once a day


Maintenance: 1-5 mg per day for every 12hrsand can increase upto less than 20 mg per day



Dose Adjustments

Dosing considerations
To prevent syncope first dose and subsequent dose preferred at bedtime and can be taken with food

labetalol

100

mg

Orally

every 12 hrs

initially; increased up to100 mg for 12hrs every 2-3 days Usual dosage range: 200-400 mg orally every 12hrs Do not exceed 2400 mg per day



trandolapril 

Nonblack patients:

1

mg

orally

every day


black patients: 2 mg orally every day
Maintenance dose
2-4 mg orally every day or divided in every 12 hours



mecamylamine 

2.5

mg

Orally 

twice a day

; increase to 2.5 mg for at least 2 days



diltiazem 

Extended-release capsules:

Initial dose: 120-240mg orally once a day, increasing the dose as needed
Maintenance dose: 120 to 540mg orally once every day
Maximum dose:540mg/day

Extended-release coated capsules
Initial dose: 120-180mg orally once a day; increase the dose as needed
Maintenance dose: 240 to 360mg orally every day
Maximum dose: 480mg/day

Extended-release tablets
Initial dose: 180 to 240mg orally once a day; increase the dose as needed
Maintenance dose: 540mg orally every day



acebutolol 

400 - 1200

mg/day

Capsule

Orally 

every 12 hours



bumetanide 

off-label:

1

mg

Intravenous (IV)

loading dose, followed by 0.5-2 mg/day oral divided every 12 hours.



amlodipine/telmisartan 

Initial dose: Initiate with 40mg/5mg or 80mg/5mg orally every day. Do not exceed 80mg/10mg every day
Maximum dose: Telmisartan 80mg-amlodipine 10mg orally every day



Dose Adjustments

Hepatic impairment
Start with a lower dose of 2.5 mg amlodipine and increase the amount gradually

Renal impairment
Dosage adjustment is not required

hydrochlorothiazide/aliskiren 

Initial dose-12.5mg/150mg or 25mg/150mg orally every day; can increase the dose if needed after 2-4 weeks. Do not exceed 300mg/25mg
Maintenance dose-25mg/300mg orally every day



Dose Adjustments

Renal impairment
CrCl<30ml/min: caution is needed for the use. When CrCl is below 30 mL/min, hydrochlorothiazide is typically ineffective and contraindicated in anuric individuals; aliskiren has the potential to cause hyperkalemia and progressive renal failure
CrCl>30ml/min: No dosage adjustment is needed

Hepatic impairment
No dosage adjustment needed

amlodipine/olmesartan 

Initial dose:5mg/20mg orally once a day, can increase the dose after 1-2 weeks
Maintenance dose-10mg/40mg orally once a day



lisinopril/hydrochlorothiazide 

Initial dose-10 to 80mg/6.25 to 50mg orally once a day. May increase the dose after 2 to 3 weeks. Do not exceed 80mg/50mg per day



eprosartan/hydrochlorothiazide 

600mg/12.5mg to 600mg/25mg orally everyday



valsartan/hydrochlorothiazide 

Initial dose: 1 tablet (80-160mg valsartan/12.5-25mg hydrochlorothiazide) per day orally
Maintenance dose: May increase the dose after 1-2 weeks to a maximum dose of 320mg valsartan/25mg hydrochlorothiazide daily



Dose Adjustments

Renal impairment
CrCl less than 30 mL/min: Because hydrochlorothiazide is not anticipated to be filtered into the renal tubule, which is where it acts when the glomerular filtration rate is less than 30 mL/min, hydrochlorothiazide-valsartan is not advised

methyldopa/hydrochlorothiazide 

methyldopa 500mg/hydrochlorothiazide 30 to 50mg orally every day
methyldopa 250mg/hydrochlorothiazide 25mg orally twice a day or methyldopa 250mg/hydrochlorothiazide 15mg orally twice or thrice a day
Do not exceed 50mg of hydrochlorothiazide every day



Dose Adjustments

Renal impairment
In patients with creatinine clearance (CrCl) of less than 30 mL/min, valsartan/hydrochlorothiazide should be avoided due to the potential for azotemia (elevated blood urea nitrogen and creatinine levels)

moexipril/hydrochlorothiazide 

moexipril 7.5mg to 15mg/hydrochlorothiazide 12.5 to 25mg orally before a meal once a day
If hydrochlorothiazide 25 mg once a day monotherapy is effective in controlling blood pressure, but considerable potassium loss still occurs, hydrochlorothiazide 6.25 mg-moexipril 3.75 mg may be used to manage blood pressure without causing electrolyte disturbances (one-half of a hydrochlorothiazide 12.5-moexipril 7.5 mg tablet)



captopril/hydrochlorothiazide 

25 - 15

mg-- captopril/hydrochlorothiazide

Orally 

every day


Do not exceed 150 mg/50 mg captopril/hydrochlorothiazide



clonidine/chlorthalidone 

0.1 - 0.3

mg/15 mg

Orally 

every day or divided into 2 times a day



Do not exceed 0.6 mg/30 mg per day



nifedipine 

30 - 60

mg

Tablets (extended release)

Orally 

once a day

7 - 14

days

when required<
should not exceed more than 120 mg/day (Procardia XL) or 90 mg/day (Adalat CC)



quinapril/hydrochlorothiazide 

(10 mg/12.5 mg) or (20 mg/12.5 mg) orally each day Increase the dose from either of the drug components based on the clinical response Do not increase the hydrochlorothiazide part more than every 2-3 weeks



Dose Adjustments

Renal impairment- When CrCl ≥30 mL/min; no dose modification is required When CrCl <30 mL/min/1.73 m² or the serum creatinine ≥3 mg/dL, the drug is not recommended

metoprolol/hydrochlorothiazide 

Renal impairment-
In case of renal impairment, use the medication with caution
Thiazides may develop a cumulative effect if given in the impaired renal function :

Lopressor HCT: 50-100 mg metoprolol tartrate and 25-50 mg hydrochlorothiazide orally each day as single or divided doses
Dutoprol: 25-100mg metoprolol succinate and 12.5 mg hydrochlorothiazide orally each day as a single dose
The drug is not indicated for initial therapy



candesartan/hydrochlorothiazide 

16-32 mg candesartan and 12.5-25 mg hydrochlorothiazide orally each day; the therapeutic effect is expected within 4 weeks



propranolol/hydrochlorothiazide 

1 tablet (40/25 mg) orally every 12 hours. If the propranolol dose is more than 160 mg, do not use the combination of the two drugs



Dose Adjustments

Renal impairment-
In case of renal impairment, use the dose with caution
Hepatic impairment-
Adjust the dose in case of severe hepatic impairment

benazepril 

1 tablet (2.5/10 mg) orally each day. Titrate an appropriate dose to control the blood pressure.
Do not increase the dose to more than 10/80 mg per day



benazepril 

1 tablet (2.5/10 mg) orally each day. Titrate an appropriate dose to control the blood pressure.
Do not increase the dose to more than 10/80 mg per day



Dose Adjustments

Renal impairment-
In case of renal impairment, when CrCl<30 ml/min, decrease the dose
In case of severe renal impairment, co-administer the dose with a diuretic
Hepatic impairment-
2.5 mg based on the initial dose of amlodipine

benazepril 

1 tablet (2.5/10 mg) orally each day. Titrate an appropriate dose to control the blood pressure.
Do not increase the dose to more than 10/80 mg per day



Dose Adjustments

Renal impairment-
In case of renal impairment, when CrCl<30 ml/min, decrease the dose
In case of severe renal impairment, co-administer the dose with a diuretic
Hepatic impairment-
2.5 mg based on the initial dose of amlodipine

benazepril 

1 tablet (2.5/10 mg) orally each day. Titrate an appropriate dose to control the blood pressure.
Do not increase the dose to more than 10/80 mg per day



Dose Adjustments

Renal impairment-
In case of renal impairment, when CrCl<30 ml/min, decrease the dose
In case of severe renal impairment, co-administer the dose with a diuretic
Hepatic impairment-
2.5 mg based on the initial dose of amlodipine

benazepril/hydrochlorothiazide 

1 tablet (2.5/10 mg) orally each day. Titrate an appropriate dose to control the blood pressure.
Do not increase the dose to more than 10/80 mg per day



valsartan/amlodipine 

Initially, 5 mg/160 mg orally each day
Titrate an appropriate dose to control the blood pressure.
Increase the dose after 2 weeks. Do not exceed the dose of more than 10 mg/day for amlodipine and 320 mg/day for valsartan



Dose Adjustments

Renal impairment-
In case of moderate renal impairment, dose adjustment is not required
In severe renal impairment (CrCl>30 ml/min), dose adjustment is not studied
Hepatic impairment-
Increase the dose in case of hepatic impairment

pindolol 

5

mg

Orally 

twice a day; may increase up to 10 mg

3 - 4

week



amlodipine/valsartan/hydrochlorothiazide 

12.5-25mg hydrochlorothiazide/ 5-10mg amlodipine/160-320 mg valsartan/ every Day
if needed May increase dose after 2 weeks
But should not exceed more than 10 mg/320 mg/25 mg orally once daily



Dose Adjustments

Renal & Hepatic Impairment
Renal impairment

Dose adjustment is not necessary with mild to moderate
Safety and efficacy not established with severe
Hepatic impairment amlodipine: half-life is increased to 56 hr with an impaired hepatic function and metabolised by liver
valsartan: dose adjustment not necessary with mild to severe hepatic impairment
hydrochlorothiazide: alterations of fluid and electrolyte balance in patients with impaired hepatic function may lead to hepatic coma

mistletoe 

Herb or crude fruit in the form of tea
10g/day



indapamide 

Begin with 1.25 mg orally every morning then the dose can be raised every 4 weeks to a maximum of 5 mg every morning



guanabenz 

Initial dose: Administer 4mg orally twice a day, with the possibility of dose increases of 4 to 8 mg/day every 1 to 2 weeks.
Maintenance dose: Administer 4 to 16mg orally twice a day
Do not exceed 32mg orally twice a day



nebivolol/valsartan 

1 tablet orally every day
Dosage Modifications
Hepatic impairment
Mild: dose modification not required
Moderate: Not suggested
Severe: not suggested
Renal impairment
Mild or moderate: dose modification not required
Moderate and severe: study not performed



amlodipine/perindopril 


Initial dose: Administer 2.5mg/3.5mg orally with or without the food every day
Wait 7–14 days between titration stages and adjust dosage in accordance with blood pressure objectives.
Do not exceed 10mg/14mg every day



Dose Adjustments

Renal impairment
CrCl 30 to 80ml/min: No to exceed 5/7mg
CrCl<30ml/min: Not suggested

Hepatic impairment
Dosing suggestions are unsupported

fosinopril/hydrochlorothiazide 

Initial oral dose: 10 mg/12.5 mg every day
Dosage range: 10-80 mg/12.5-50 mg orally every day
Combination treatment recommended for individuals who have insufficiently controlled blood pressure with either fosinopril or hydrochlorothiazide as standalone therapies



perindopril 

4 - 8

mg

every day

or divided 2 times a day; increase up to 16 mg/day
Diuretic may be added



olmesartan 

20

mg/day

Orally 

; increased to 40 mg after 2 weeks
Following may be Diuretic added



spironolactone and hydrochlorothiazide 

1-2 tablets/day orally (hydrochlorothiazide 50 mg/ spironolactone 50 mg)
2-4 tablets/day orally (hydrochlorothiazide 25 mg/ spironolactone 25 mg)



Dose Adjustments

Renal Impairment
hydrochlorothiazide efficacy decreased when CrCL <30 mL/min
Hepatic Impairment
Contraindicated in Acute or severe hepatic failure

hydralazine 

Take a dose of 10 mg orally every 6 hours for 2 to 4 days; also take a dose of 25 mg every 6 hours daily for the initial week
Then raise dose up to 50 mg every 6 hour from next week
Administer a dose of 20 to 40 mg intramuscularly or intravenously and repeat as required



nicardipine 

Take 20 to 40 mg orally every 8 hours
Administer dose of 5 mg/hr intravenously by slow infusion initially and it may be raised by 2.5 mg/hr every 15 minutes
Not more than 15 mg/hr



eprosartan 


Indicated for Hypertension
Initial Dose:600mg orally every day
Maintenance Dose:400-800mg orally every day or in divided doses two times a day.
Renal Impairment
The patient should be carefully monitored. The maximum daily dosage should not exceed 600 mg
Hepatic Impairment
The patient should be carefully monitored. The maximum daily dosage should not exceed 600 mg



cilazapril/hydrochlorothiazide 

Take dose of cilazapril 2.5 to 10 mg with hydrochlorothiazide 6.25 to 25 mg daily
Dosage modification
Renal Impairment
CrCl ≥10 ml/minute: reduced dose of cilazapril
CrCl <10 ml/minute: not suggested
Hepatic Impairment
Reduced dose of cilazapril



cilazapril 

Take an initial dose of 2.5 mg one time a day
Maximum dose not more than 10 mg one time a day
Dosing modifications
Renal Impairment
For Heart failure
CrCl >40 ml/minute: take initial dose of 0.5 mg one time a day
CrCl 10 to 40 ml/minute: take initial dose of 0.25 to 0.5 mg one time a day
CrCl <10 ml/minute: Use not suggested
For Hypertension
CrCl >40 ml/minute: take initial dose of 1 mg one time a day
CrCl 10 to 40 ml/minute: take initial dose of 0.5 mg one time a day
CrCl <10 ml/minute: Use not suggested
Hepatic Impairment
For Hypertension
Take initial dose of ≤0.5 mg one time a day and use cautiously



enalapril 

Oral
Initial dose: 2.5 to 5 mg orally every day
Maintenance dose: 10 to 40 mg orally every day or divided every 2 times a day
Intravenous
1.25 mg/dose Intravenous over 5 minutes every 4 times a day; doses till 5 mg/dose Intravenous every 4 times a day can be administered



losartan/hydrochorothiazide