A simple stepped regimen in keeping with the 1999 British Hypertension Society guidelines30 is the AB/CD schema illustrated in Figure 23.2:33
1. Depending on the patient's age (see above) use either a p Blocker or thiazide Diuretic as firstline therapy, unless there is a compelling reason to avoid these (e.g. asthma and gout, respectively). If the first drug is effective but not tolerated, switch to the other member of the pair: i.e. ACE inhibitor (or AIIRA) instead of P-blocker, Calcium blocker instead of diuretic.
2. If the blood pressure is not controlled in
4 weeks by the first-line drug then switch to a
33 Dickerson J E C et al 1999 Lancet 353: 2008-2013.
drug from the other pair, e.g. a thiazide Diuretic should be replaced by a P-Blocker, and vice versa.
3. If the blood pressure is still not controlled, a second agent should be added, using the opposite pair to the first drug e.g. if the patient is on an ACE inhibitor add a Calcium channel blocker or thiazide Diuretic (A+C or A+D), since both vasodilatation or diuresis will stimulate the renin-angiotensin system and turns nonrenin-dependent hypertension into renin-dependent hypertension). The combination B+D is associated with increased risk of diabetes and should be avoided in at-risk patients (obesity, family history). The combinations A+B or C+D usually produce a less than additive effect on blood pressure, but should be tried in patients still uncontrolled on more standard combinations.
4. If blood pressure control is still inadequate on dual therapy A+C+D is the ideal triple regimen.
4a. If additional therapy is required, a-blockade is effective at this stage by blocking the vasoconstrictor component of the baroreflex response to some of the other drugs. A very
AB/CD Rule for optimisation of antihypertensive treatment
(AB/CD =ACEi, Beta-b I ocker/Ca++-blocker, Diuretic)
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