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Combination ACD drug therapy in hypertension

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

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


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)


  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)

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