michigan hypertension core curriculum - State of Michigan

Treatment of Secondary Causes of Hypertension
When renal artery stenosis, obstructive sleep apnea, primary aldosteronism,
pheochromocytoma, or Cushing’s disease is suspected or confirmed, treatment will be specific for that
particular disorder.
Pharmacological Treatment
The best approach to treat RH has not been directly evaluated in randomized trials and the
choice of treatment regimen is based largely on physiological principles and clinical experience.
Because volume overload is common among such patients, the most important therapeutic maneuver
is generally to add or increase diuretic therapy. 23 It is important to ensure that the diuretic is
appropriate to the level of kidney function. Also, sometimes utilization of more than one diuretic will
be necessary in complex, multi-drug regimens. Another important therapeutic maneuver is to titrate
BP medication up to ideal doses and, or to use effective combinations of BP medications 27 and. 2 The
medication regimen should be examined closely for ineffective antihypertensive drug combinations.
Withdrawal of Interfering Medications particularly NSAIDs and Cox II inhibitors if possible. 2
Therefore, if analgesics are necessary, sulindac or acetaminophen or even mild narcotic pain
medications may be preferable to most NSAIDs in subjects with resistant hypertension.
Diuretic Therapy as explained above is very essential to overcome the inappropriate volume
expansion seen in RH and it is in fact essential aspect of the definition of resistant HTN.
Thiazide diuretics:
While Hydrochlorothiazide is widely used and effective in treating HTN in patients with
normal renal function; Chlorthalidone is the recommended and the most effective thiazide diuretic for
resistant HTN. 2 The extremely long half-life of 40 to 60 hours for chlorthalidone differentiates it from
HCTZ, which has a much shorter half-life from 3.2 to 13.1 hours. 28 However chlorthalidone might be
associated with excessive degrees of hypokalemia and requires more monitoring 28 ; however, this is
of much less concern when chlorthalidone is used together with RAAS blockers given that the latter
reduces the incidence of hypokalemia by two-thirds to three quarters. Chlorthalidone also, in contrast
to hydrochlorothiazide, is available only in few fixed-dose combinations and generally requires separate
dosing. 2 Metolazone, a long-acting thiazide-like diuretic, is highly effective in persons with depressed
kidney function
230 Hypertension Core Curriculum