People’s Pharmacy | Finding the best blood pressure medicine is challenging
High blood pressure is one of the most common conditions affecting Americans. The CDC estimates that nearly half of adults in the US have hypertension. That comes out to 120 million people.
The latest guidelines encourage healthcare professionals to get patients’ blood pressure under 120/80. That can be a challenge.
There is no scientific way to predict which antihypertensive medicine will work best for any given individual. As a result, both doctors and patients participate in a lengthy experiment, otherwise known as trial and error.
For decades, doctors started with a class of drugs called beta blockers. Medicines like atenolol, metoprolol and propranolol were widely prescribed. In recent years, though, such medications have fallen out of favor as first line treatments for hypertension.
An independent review by the Cochrane Collaboration found that hypertension treatment with beta blockers reduced cardiovascular disease only modestly, with little to no effect on mortality (Cochrane Database of Systematic Reviews, Jan. 20, 2017). The authors concluded, “These beta-blocker effects are inferior to those of other antihypertensive drugs.” Moreover, they noted that many people on beta blockers stopped taking them due to side effects.
Readers of this column often complain about hair loss, dizziness, fatigue and shortness of breath. But beta blockers should never be stopped suddenly. There is a possibility that doing so could precipitate heart problems.
These days, the most commonly prescribed BP medications are ACE (angiotensin-converting enzyme) inhibitors. Over 20 million Americans take lisinopril daily. For most people, the drug controls hypertension well without many complications.
One of the most common complaints, though, is an uncontrollable cough that can be extremely disruptive. It may not show up for years, as this reader describes: “I took this drug for about 10 years before a horrible cough occurred–no congestion, just an annoying cough that impacted work and meetings.
“My primary physician jumped on lisinopril right away. She told me some literature says 5 to 10 percent eventually develop the cough, but in her practice, she said it was more like 33 percent.”
People who have trouble with lisinopril may be offered losartan or valsartan as an alternative. These drugs are angiotensin II receptor blockers (ARBs). They work at a different point on the same pathway as ACE inhibitors, so they have similar advantages but are less likely to cause problems like cough.
A recent analysis suggests that many patients do well on a combination of blood pressure-lowering medications, especially ARBs with calcium channel blockers (CCBs) like amlodipine (JAMA, May 28, 2026). One downside of CCBs is fluid retention. Swollen ankles are a common complaint, but they are less likely if a person is also taking an ACE inhibitor, an ARB or a diuretic.
Whatever medication is selected, dizziness can often be a serious complication. People on BP drugs may need to stand up slowly to avoid what doctors call orthostatic hypotension. Falls can lead to fractures, particularly in older people.
Selecting the best medicine for any given individual still requires a trial-and-error process. Sometimes a medicine that works well for months or years can unexpectedly cause adverse reactions, such as a life-threatening allergic reaction called angioedema. Patients and doctors must work together to find the safest and most effective combination.
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In their column, Joe and Teresa Graedon answer letters from readers. Write to them in care of this newspaper or e-mail them via their Web site: www.peoplespharmacy.com. Their newest book is Top Screwups Doctors Make and How to Avoid Them (Crown).