(Hypertension)

This leaflet is about medicines that are used to treat high blood pressure.
See separate leaflet called High Blood Pressure (Hypertension),
which gives more general information about high blood pressure,
lifestyle changes that you can do to lower blood pressure, and the
reasons why medication is advised to lower blood pressure in some
cases.

What is the aim of treatment?

Your doctor or practice nurse will advise on the target blood pressure level to aim for. It can vary
from person to person. In general:

For most people aged under 80 years, the usual target is to reduce blood pressure to 140/90
mm Hg or below in the surgery or clinic, or below 135/85 mm Hg when measured at home. For
older patients the target may be set slightly higher (less than 150/90 mm Hg in the surgery or
clinic, or below 145/85 mm Hg when measured at home).

In some people, the target is to get it below 130/80 mm Hg. For example, if you have a
cardiovascular disease such as a stroke or heart disease, if you have certain kidney diseases,
and for some people with diabetes.

Which medicines are used to lower blood

pressure?
There are five main classes of medicines that are used to lower blood pressure. There are various
types and brands of medicine in each class. The following gives a brief overview of each of the
classes. However, for detailed information about your own medication you should read the leaflet
that comes inside the medicine packet.

Angiotensin-converting enzyme (ACE) inhibitors

ACE inhibitors work by reducing the amount of a chemical that you make in your bloodstream, called
angiotensin II. This chemical tends to narrow (constrict) blood vessels. Therefore, less of this
chemical causes the blood vessels to relax and widen, and so the pressure of blood within the blood
vessels is reduced.
There are various types and brands of ACE
inhibitors: captopril, enalapril, fosinopril,lisinopril, perindopril, quinapril, ramipril, and trandolapril. An
ACE inhibitor is particularly useful if you also have heart failure or diabetes. ACE inhibitors should
not be taken by people with certain types of kidney problems, people with some types of artery
problems, and those who are pregnant. You will need a blood test before starting an ACE inhibitor.
This will check that your kidneys are working well. The blood test is repeated within two weeks after
starting the medicine, and within two weeks after any increase in dose. Then, a yearly blood test is
usual.

Angiotensin receptor blockers

These medicines are sometimes called angiotensin-II receptor antagonists. There are various types
and brands:candesartan, eprosartan, irbesartan, losartan, olmesartan,telmisartan and valsartan.
They work by blocking the effect of angiotensin II on the blood vessel walls. So, they have a similar
effect to ACE inhibitors (described above).

Calcium-channel blockers
Calcium-channel blockers affect the way calcium is used in the blood vessels and heart muscle. This
has a relaxing effect on the blood vessels. Again, there are various types and
brands: amlodipine, diltiazem, felodipine, lacidipine,lercanidipine, nicardipine, nifedipine, and verapa
mil. Calcium-channel blockers can also be used to treatangina.

'Water' tablets (diuretics)

Diuretics work by increasing the amount of salt and fluid that you pass out in your urine. This has
some effect on reducing the fluid in the circulation, which reduces blood pressure. They may also
have a relaxing effect on the blood vessels, which reduces the pressure within the blood vessels.
The most commonly used diuretics to treat high blood pressure (hypertension) in the UK

are thiazides or thiazide-like diuretics. Examples

are bendroflumethiazide,chlortalidone, cyclopenthiazide, and indapamide. Only a low dose of a
diuretic is needed to treat high blood pressure. Therefore, you will not notice much diuretic effect
(that is, you will not pass much extra urine). You will need a blood test before starting a diuretic, to
check that your kidneys are working well. You should also have a blood test within 4-6 weeks of
starting treatment with a diuretic, to check that your blood potassium has not been affected. Then, a
yearly blood test is usual.

Beta-blockers
Again, there are various types and brands of betablockers: acebutolol, atenolol,bisoprolol, metoprolol, oxprenolol, pindolol, propranolol, sotalol,
and timolol. They work by slowing the heart rate, and reducing the force of the heart. These actions
lower the blood pressure. Beta-blockers are also commonly used to treat angina, and some other
conditions. You should not normally take a beta-blocker if you have asthma, chronic obstructive
pulmonary disease (COPD), or certain types of heart or blood vessel problems.

What about side-effects?

All medicines have possible side-effects, and no medicine is without risk. However, most people who
take medicines to lower blood pressure do not develop any side-effects, or only have mild sideeffects. A full list of cautions and possible side-effects is listed on the leaflet inside the medicine
packet. The most common ones are:

ACE inhibitors - sometimes cause an irritating cough.

Angiotensin receptor blockers - sometimes cause dizziness.

Calcium-channel blockers - sometimes cause dizziness, facial flushing, swollen ankles,

and constipation.

'Water' tablets (diuretics) - can cause gout attacks in a small number of users, or can make
gout worse if you already have gout. Erection problems (impotence) develop in some users.

Beta-blockers - can cause cool hands and feet, poor sleep, tiredness, and impotence in
some users.

If you do develop a side-effect, a different medicine may suit you better. There is a lot of choice so
one can usually be found to suit. See your doctor if you develop any problem which you think is due
to your medication.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines you can report this on the Yellow
Card Scheme. You can do this online at the following web address:www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new sideeffects that medicines may have caused. If you wish to report a side-effect, you will need to provide
basic information about:

The side-effect.

The name of the medicine which you think caused it.

Information about the person who had the side-effect.

Your contact details as the reporter of the side-effect.

It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill
out the report.

Other medicines for high blood pressure

Apart from the five main classes of medicines listed above, sometimes other medicines are used to
lower blood pressure. For example, methyldopa or alpha-blockers are sometimes used if there are
problems with the more commonly used medicines.

Combinations of medicines
One medicine can reduce high blood pressure (hypertension) to the target level in less than half of
cases. It is common to need two or more different medicines to reduce high blood pressure to a
target level. In about a third of cases, three medicines or more are needed to get blood pressure to
the target level. So, for example, you may need an ACE inhibitor plus a calcium-channel blocker

(and sometimes also another medicine) to control your blood pressure. This is just an example, and
various combinations of medicines can be used.
In some cases, despite treatment, the target level is not reached. However, although to reach a
target level is ideal, you will gain benefit from any reduction of high blood pressure.

So, which is the best medicine or

combination of medicines?
The one or ones chosen may depend on such things as:

Whether you have other medical problems.

Your ethnic origin.

Whether you take other medication.

Possible side-effects.

Your age.

For example:

Beta-blockers and calcium-channel blockers can also treat angina.

ACE inhibitors also treat heart failure.

Some medicines are not suitable if you are pregnant.

Some medicines are thought to be better if you have diabetes.

Some medicines tend to work better than others in people of Afro-Caribbean origin.

If you do not have any other medical problems that warrant a particular medicine then current UK
guidelines give the following recommendations as to usual medicines that should be used. These
recommendations are based on treatments and combinations of treatments that are likely to give the
best control of the blood pressure with the least risk of side-effects or problems.

Treatment is guided by the A/C, A+C, A+C+D approach, where A = ACE inhibitor or angiotensin
receptor blocker; C = calcium channel blocker and D = diuretic. The suggested stepwise approach is
as follows:

If you are less than 55 years old and are not of black African or Caribbean origin then your
doctor may begin treatment with an 'A' (an ACE inhibitor, or an angiotensin receptor blocker if
an ACE inhibitor causes problems or side-effects).

If you are 55 years or older, or are of black African or Caribbean origin then your doctor may
begin treatment with a 'C' (a calcium-channel blocker).

Then, if your blood pressure has not reached the target your doctor may combine 'A' with 'C'
(an ACE inhibitor or an angiotensin receptor blocker plus a calcium-channel blocker).

Then, if your target blood pressure is still not reached, your doctor may combine 'A' with 'C'
and 'D' (an ACE inhibitor or an angiotensin receptor blocker, and a calcium-channel blocker,
and a diuretic).

If a fourth medicine is needed to achieve the target blood pressure, your doctor may add one
of the following:

A beta-blocker

Another 'water' tablet (diuretic)

An alpha-blocker

However, individuals can vary. Sometimes, if one medicine does not work so well or causes sideeffects, a switch to a different class of medicine may work fine.

How long is medication for high blood

pressure needed for?
In most cases, medication is needed for life. However, in some people whose blood pressure has
been well-controlled for three years or more, medication may be able to be stopped. In particular, in
people who have made significant changes to lifestyle which can affect blood pressure (such as lost

a lot of weight, or stopped heavy drinking, etc). Your doctor can advise. If you stop medication, you
need regular blood pressure checks. In some cases, the blood pressure remains normal. However,
in others it starts to rise again. Medication can then be started again.