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Last reviewed dd mmm yyyy. Last edited dd mmm yyyy
The guidance regarding combination treatment of systemic hypertension has been updated (1):
BP targets in adults:
Starting antihypertensive drug treatment
Offer antihypertensive drug treatment in addition to lifestyle advice to adults of any age with persistent stage 2 hypertension. Use clinical judgement for people of any age with frailty or multimorbidity.
Discuss starting antihypertensive drug treatment, in addition to lifestyle advice, with adults aged under 80 with persistent stage 1 hypertension who have 1 or more of the following:
Consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%
Consider antihypertensive drug treatment in addition to lifestyle advice for people aged over 80 with a clinic blood pressure of over 150/90 mmHg
Measure standing as well as seated blood pressure in people with hypertension and:
Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or more) the same treatment as people with both raised systolic and diastolic blood pressure
For adults aged under 40 with hypertension, consider seeking specialist evaluation of secondary causes of hypertension and a more detailed assessment of the long-term balance of treatment benefit and risks
Choosing antihypertensive drug treatment
Step 1 treatment
Offer an ACE inhibitor or an ARB to adults starting step 1 antihypertensive treatment who:
If an ACE inhibitor is not tolerated, for example because of cough, offer an ARB to treat hypertension.
Do not combine an ACE inhibitor with an ARB to treat hypertension
Offer a calcium-channel blocker (CCB) to adults starting step 1 antihypertensive treatment who:
If a CCB is not tolerated, for example because of oedema, offer a thiazide-like diuretic to treat hypertension.
If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE guidance on management of heart failure
If starting or changing diuretic treatment for hypertension, offer a thiazide-like diuretic, such as indapamide in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide
For adults with hypertension already having treatment with bendroflumethiazide or hydrochlorothiazide, who have stable, well-controlled blood pressure, continue with their current treatment
Step 2 treatment
If hypertension is not controlled in adults taking step 1 treatment of an ACE inhibitor or ARB, offer the choice of 1 of the following drugs in addition to step 1 treatment:
If hypertension is not controlled in adults taking step 1 treatment of a CCB, offer the choice of 1 of the following drugs in addition to step 1 treatment:
If hypertension is not controlled in adults of black African or African-Caribbean family origin who do not have type 2 diabetes taking step 1 treatment, consider an ARB, in preference to an ACE inhibitor, in addition to step 1 treatment
Step 3 treatment
If hypertension is not controlled in adults taking step 2 treatment, offer a combination of:
Step 4 treatment
If hypertension is not controlled in adults taking the optimal tolerated doses of an ACE inhibitor or an ARB plus a CCB and a thiazide-like diuretic, regard them as having resistant hypertension.
Before considering further treatment for a person with resistant hypertension:
For people with confirmed resistant hypertension, consider adding a fourth antihypertensive drug as step 4 treatment or seeking specialist advice
Consider further diuretic therapy with low-dose spironolactone for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of 4.5 mmol/l or less. Use particular caution in people with a reduced estimated glomerular filtration rate because they have an increased risk of hyperkalaemia
When using further diuretic therapy for step 4 treatment of resistant hypertension, monitor blood sodium and potassium and renal function within 1month of starting treatment and repeat as needed thereafter
Consider an alpha-blocker or beta-blocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.5mmol/l.
If blood pressure remains uncontrolled in people with resistant hypertension taking the optimal tolerated doses of 4 drugs, seek specialist advice
Stage 1 hypertension
Stage 2 hypertension
Stage 3 or severe hypertension