Combination ACD drug therapy in hypertension

The guidance regarding combination treatment of systemic hypertension has been updated by NICE (1):

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In people with CKD and diabetes, and also in people with an ACR of 70 mg/mmol or more, aim to keep the systolic blood pressure below 130 mmHg (target range 120-129 mmHg) and the diastolic blood pressure below 80 mmHg (1)

Notes about add-on therapy:

• spironolactone is an effective treatment for primary hyperaldosteronism (defined as an elevated plasma aldosterone-to-renin ratio) - thus if a patient is uncontrolled despite triple therapy then a plasma renin should be measured off beta-blockade (which suppresses renin) as part of consideration of secondary causes of hypertension (2).
• often the last resort in terms of treatment options is minoxidil (a powerful vasodilator) (2) - this however requires careful titration in combination with a loop diuretic and beta-blocker - also side effects include hirsutism and coarsening of facial features; the difficulties with using minoxidil lead some specialists to try additional diuretic therapy before initiating minoxidil treatment
• *combination therapy involving beta blockers and D may induce more new onset type 2 diabetes compared other combinations of drug therapy (3)

Reference:

1. NICE (November 2016). Hypertension - management of hypertension in adults in primary care.
2. J Hum Hypertens. 2003 Feb;17(2):81-6.
3. email correspondence from British Hypertension Society Information Officer (10/11/003)