Monitoring

The blood pressure must be monitored by a doctor or specialist nurse (particularly important in the old) and also sometimes by the patient. 24-hour ambulatory blood pressure monitoring (ABPM) is possible with an increasing number of user-friendly, semi-automatic devices. They are too expensive to be recommended for most patients. 24-h blood pressure predicts outcome better than clinic blood pressure and is therefore useful in influencing the need for extra treatment in difficult or high-risk patients. Home monitoring is a cheaper alternative, providing the sphygmomanometer has been validated. The easy-to-use wrist monitors are unfortunately unreliable in patients receiving drug treatment.

Diuretics and potassium. The potassium-losing (kaliuretic) diuretics used in hypertension deplete body potassium by 10-15%. Potassium chloride supplements are not required routinely, but hypokalemia will occasionally occur (and should raise suspicion of Conn's syndrome). Uncomplicated patients may not need monitoring if the lowest possible doses are used, e.g. no more than bendro-fluazide (bendroflumethazide) 2.5 mg. Vulnerable patients, e.g. the elderly, should be monitored for potassium loss at 3 months and thereafter every 6-12 months. In general a potassium-retaining diuretic (amiloride) in a fixed-dose combination with a thiazide (co-amilozide) is preferred over the use of fixed-dose diuretic/KCl formulations (most supplements, typically 8 mmol of KC1, are in any case inadequate).

Control of potassium balance is particularly important if the patient is also taking digoxin (hypokalemia potentiates the action of digoxin). Because of the risk of hyperkalaemia, amiloride should usually be avoided in patients taking ACE inhibitors unless renal function is normal.

Compliance. Multidrug therapy poses a substantial problem of compliance. Since treatment will be lifelong it is well worthwhile taking the trouble to find the most convenient regimen for each individual. A single daily dose would be ideal and to achieve this sustained-release formulations and fixed-dose combinations are used. Examples include: Tenoretic (atenolol + chlortalidone), Tenif (atenolol + nifedipine) and Zestoretic (lisinopril + hydrochlorothiazide).

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