Master the board step 3

Nephrology
What is the most effective lifestyle modification for hypertension?
Answer: Weight loss
If lifestyle modifications have no effect over 3–6 months, initiate medical
therapy:
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Use a thiazide diuretic, such as hydrochlorothiazide or chlorthalidone,
and a calcium blocker or ACE inhibitor.
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In diabetics, however, use ACEI/ARB as the first-line therapy.
About 60–70 percent of patients will be controlled with one drug. If pressure
control is not achieved with the first drug, add a second and possibly a third
drug:
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Beta blocker (metoprolol, carvelodil)
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ACE inhibitor
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Angiotensin receptor blocker (ARB)
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Calcium channel blocker (CCB)
About 90–95 percent of patients should achieve control with the use of 3 medications.
If 2 drugs do not work, add a third drug. Investigate for causes of
secondary hypertension if 3 drugs do not work.
Compelling Indications for Specific Medications
If any of the conditions in the following table are present, do not start with a
diuretic. Go straight to the specific medication.
Thiazides are not better
than CCBs, ACEIs, or ARBs
as a first drug.
Condition
Medication
Coronary artery disease
Congestive heart failure
Migraine
Hyperthyroidism
Osteoporosis
Depression
Asthma
Pregnancy
BPH
Diabetes
Beta blocker
Beta blocker, ACEI, or ARB
Beta blocker, CCB
Beta blocker
Thiazide
No beta blockers
No beta blockers
Alpha methyldopa
Alpha blockers
ACEI/ARB
Thiazides are not better as a first choice than beta blockers, ACE inhibitors,
or calcium channel blockers. Diabetes alone can be controlled to 140/90. Start
with 2 medications if baseline blood pressure is > 160/100.
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