II. Protocol: Step 1 (Determine when and how to intervene)

III. Protocol: Step 2

  1. Consider Hypertension Combination Therapy
    1. For Refractory Hypertensive Populations
    2. Combination therapy to start appears to be more effective than starting with monotherapy
  2. Choose agents first based on comorbidity and cohort
    1. See Hypertension Management for Specific Comorbid Diseases
    2. See Hypertension Management for Specific Populations
  3. Monotherapy (when not otherwise directed by comorbidity or cohort)
    1. Consider starting with combination tablet Lisinopril/Hctz 20/25 mg (Kaiser-Permanante)
      1. http://providers.kaiserpermanente.org/info_assets/cpp_cod/cod_adult_bp_clinician_guide.pdf
      2. Allows for dosing at 1/2 tablet (10/12.5 mg), 1 tablet, or 2 tablets (40/50 mg)
    2. Standard initial monotherapy choices
      1. Diuretics (e.g. Hydrochlorothiazide)
        1. If Diuretic is not first, it should be second
        2. Excellent adjunct to other antihypertensives
        3. Better outcomes than Lisinopril and Amlodipine
          1. Reduced risk of CVA, MI, CHF over other agents
          2. (2002) JAMA 288:2981-97 [PubMed]
      2. ACE Inhibitor or Angiotensin Receptor Blocker
        1. Preferred first-line agent in age under 60 years old
      3. Calcium Channel Blockers
    3. Compelling reason for other antihypertensive
      1. AntiHypertensives for Specific Comorbid Diseases
      2. Antihypertensives for Specific Populations
    4. Agents to avoid for monotherapy
      1. Alpha blockers
      2. Hydralazine
      3. Minoxidil
      4. Beta Blocker
        1. Trend is to avoid Beta Blockers as first-line agents in uncomplicated Hypertension
        2. Reserve for patients with Coronary Artery Disease or Congestive Heart Failure
    5. Avoid if non-compliant (rebound Hypertension)
      1. Beta Blockers
      2. Clonidine

IV. Protocol: Step 3

V. Metabolism: Antihypertensives not affected by Cytochrome P450 system

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