Medications

By Paula Kurtzweil

Treating hypertension • Hypertension drugs • Finding what works

The "silent killer" — hypertension, or high blood pressure — snuck up on my mother when she was in her 40s, making its presence known by causing congestive heart failure and resulting in several lengthy hospital stays.

Though her blood pressure measured as high as 250/150 during those initial touch- and-go days, she's maintained a much-closer-to-normal blood pressure for the past 30 years, thanks to daily doses of antihypertensive drugs.

Today's range of drugs for treating high blood pressure makes it possible for people like my mother and the nearly 50 million other Americans who suffer from high blood pressure to lead normal, healthy lives well into their senior years. Exercise, regular blood pressure checks, healthy eating, maintenance of a healthy body weight, and other lifestyle changes can make a big difference, too.

Without these treatments, people with consistently high blood pressure face increased risks for heart attack, stroke and kidney disease. High blood pressure also can cause blood vessels on the eye's retina to clog, eventually bursting and possibly damaging parts of the retina and impairing vision.

Treatment can vary with the level of elevation of the blood pressure, as well as the patient's age and health. According to FDA's Fenichel, sometimes lifestyle changes can reduce blood pressure by 5 points or so. They include stopping smoking, reducing alcohol intake, losing excess weight, and making certain dietary changes, such as reducing sodium intake and possibly increasing potassium, calcium and magnesium intake. Some experts also recommend exercise and relaxation techniques, such as meditation.

"But," Fenichel says, "treatment with drugs is the only effective approach for attaining larger reductions in blood pressure."

FDA has approved numerous drugs for treating hypertension. These drugs work in different ways but the end result — reducing blood pressure — is the same.

• Diuretics. Sometimes called "water pills," these drugs flush excess water and sodium from the body by increasing urination. This reduces the amount of fluid in the blood and flushes sodium from the blood vessels so that they can open wider, increasing blood flow and thus reducing the blood's pressure against the vessels. Often diuretics are used in combination with other high blood pressure drugs. Types of diuretics include thiazides, such as Diuril (chlorothiazide) and Esidrex (hydrochlorothiazide); potassium-sparing diuretics, such as Aldactone (spironolactone); and loop diuretics, such as Lasix (furosemide).

• Beta blockers. These drugs slow the heartbeat by blocking the effect of nerve impulses to the heart and blood vessels, thereby lessening the burden on the heart. Beta blockers include Inderal (propranolol), Lopressor (metoprolol), and Tenormin (atenolol).

• ACE (angiotensin-converting enzyme) inhibitors. These inhibit formation of the hormone angiotensin II, which causes blood vessels to narrow, thus increasing blood pressure. ACE inhibitors include Altace (ramipril), Capoten (captopril), and Zestril (lisinopril).

• Calcium channel blockers. These prevent calcium from entering the muscle cells of the heart and blood vessels, thus relaxing blood vessels and decreasing blood pressure. Some calcium channel blockers are Procardia (nifedipine), Isoptin (verapamil) and Cardiazem (diltiazem).

• Alpha-beta blockers. These combine the actions of alpha blockers, which relax blood vessels, and beta blockers, which slow the heartbeat. The dual effect reduces the amount — and thus pressure — of blood through blood vessels. Alpha-beta blockers include Normodyne and Trandate (both labetalol).

Often, combinations of two drugs from different classes are used to improve the drugs' effectiveness.

Many doctors begin newly diagnosed hypertensive patients with diuretics or beta blockers. The Sixth Report of the Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, released by NIH's National Heart, Lung, and Blood Institute in November 1997, recommends diuretics or beta blockers as the first line of treatment. However, based on a patient's situation — for example, use of other medicines — doctors may choose to start treatment with another antihypertensive drug.

Some specifics to JNC's first-line recommendation are noted in the report. For example, it recommends that in African Americans, one of the groups most at risk for hypertension, diuretics alone should be the first agent of choice — provided there are not other conditions that prohibit their use — because of this group's increased sensitivity to salt. For hypertensive people with diabetes or kidney disease, the guidelines recommend that initial drug treatments include ACE inhibitors.

Like most drugs, blood pressure medicines can have side effects, ranging from the unpleasant — such as skin rash, sleepiness and weight gain — to the severe, including depression, hallucinations, heart dysfunction, and liver disease. Patients who begin a drug treatment and develop symptoms that they did not have before should discuss them with their doctors. With the great variety of medicines, it is likely that another antihypertensive drug or dosage level can help control blood pressure with few or no side effects.

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