michigan hypertension core curriculum - State of Michigan

general, the response to beta-blocker monotherapy in African American and older patients is modest,
and therefore the combinations of beta blockers with either diuretics or dihydropyridine calcium channel
blockers can be particularly useful in this population. Dose dependent side effects of beta blockade
such as lethargy and insomnia occur less frequently with combination therapy. 3
Some antihypertensive drug combinations cannot be recommended as some combinations
may result in an unacceptable side effect profile while conferring minimal incremental BP lowering. For
example combinations of beta-blockers and centrally acting agents may add significantly to lethargy.
And, though commonly utilized in clinical practice, this combination should be avoided given the
modest incremental BP reduction afforded when two drug classes working on the sympathetic nervous
system are combined. Furthermore, this combination of antihypertensive drugs may also result in
significant bradycardia. Additionally, calcium channel blockers and vasodilators are less likely to be
effective when used together than other combinations and may exacerbate peripheral edema. 5 The
combination of an ACE inhibitor and an ARB can be useful in patients with proteinuria. However, this
combination provides little incremental BP lowering over the use of either monotherapy, is associated
with an increased risk of renal dysfunction and hypotensive symptoms, and cannot be recommended
for routine use. Nephrologists and Hypertension specialists may occasionally opt for this combination.
However, they will do so with clear vigilance for hyperkalemia, adverse symptoms, and worsening
kidney function.
Used effectively, combination therapy can improve adherence by minimizing side effects and
reducing pill burden. Utilizing half-maximum doses of individual agents in combination with additional
agents can provide the most effective treatment for patients and should be utilized whenever more
than one medication is needed. Thoughtful use of combination therapy can help to decrease HTN
associated morbidity and mortality through improved HTN control.
206 Hypertension Core Curriculum