The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from any one of the classes in the recommended list (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. Clinicians should recognize that evidence behind each medication is based on the use of a specific (high) target dose.   The JNC 8 treatment algorithm is a suggested management guide but should not replace individual clinical judgment or patient preference.

If goal BP cannot be reached with 2 drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs recommended in JNC 8, because of a contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy, or for the management of otherwise complicated patients. Remember that most hypertensive patients will require two or more medications to gain control. (Expert Opinion – Grade E; JNC 8)

 Expense and Patient Convenience

• Generic drugs reduce costs to patients, institutions, and society as a whole. Generic drugs are as effective as their brand name counterparts. An example is generic lisinopril which costs approximately $18.99 a month for a 30 day supply of 5mg tablets. A brand name version of lisinopril costs approximately $34.58 a month for a 30 day supply of 5mg tablets.
• Use 24 hour formulations of medications whenever possible. These formulations allow 50% of the medication to still be in the system 24 hours later, and keep drug levels and blood pressures levels that are constant all day. Patients also prefer taking a one a day drug over those that are taken several times a day.
• Consider combination medications when a patient has achieved blood pressure control with separate medications. For example, a patient with excellent blood pressure control on losartan 100mg/day and hydrochlorothiazide 25mg/day will have a reduced pill burden with one combination pill a day of losartan/hydrochlorothiazide 100mg/25mg a day.

Tobacco

• Nicotine increases blood pressure and reduces the efficacy of blood pressure medications
• Hypertensive patients should be vigorously encouraged towards smoking reduction and cessation at every visit by their physicians.

Mary Johnson and Her Initial Treatment Plan

We return to your patient, Mary Johnson, a 39 year old African American, non-smoking female recently diagnosed with asymptomatic Stage 1 Hypertension. Her initial laboratory tests were all within normal limits. You have counseled her on lifestyle modifications and are now ready to start drug therapy.

What would you recommend as initial drug treatment in Mary Johnson?

Follow Up and Monitoring

• Patients should return for monthly follow up and adjustment of medications until the BP goal is reached.
• More frequent visits for stage 2 hypertension or with complicating co-morbid conditions.
• Serum potassium and creatinine should be monitored 1–2 times per year.
• After blood pressure is at goal and stable, follow up visits at 3- to 6-month intervals.
• Although not mentioned in JNC 7 or JNC 8, consideration should be given to periodic rechecking fasting cholesterol panels and glucose, and possibly urine microalbumin if initial surveillance was negative.

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