Managing hypertension in problem patient populations

Hypertension complicated by underlying pathological and physiological factors necessitates special considerations when prescribing therapy. BP must be effectively reduced in these patients without aggravating concomitant medical problems.

Antihypertensive therapy is well tolerated by most elderly patients but their response to drugs may be affected by age-related pathological and physiological changes. Elevated BP as a result of renal artery stenosis should be identified early to allow curative surgical treatment to be carried out.

Black populations appear to have a genetic predisposition to hypertension and exhibit a high rate of end organ damage leading to significant morbidity and mortality. Physiological differences between black and white patients must be considered when prescribing antihypertensive therapy.

Weight reduction and restricted salt intake should precede drug therapy, particularly In obese and diabetic patients. Low dose diuretic therapy may be prescribed for elderly patients if non-drug therapy proves unsuccessful Low dose thiazides or thiazide-like diuretics are recommended as Initial antihypertensive therapy in black patients. Aggressive treatment with larger doses, although often necessary, may cause metabolic disturbances in black and diabetic patients. Monotherapy with calcium antagonists may be initiated if diuretic therapy fails to reduce BP adequately

Alternatively, calcium antagonists, fj-blockers, ACE-Inhibitors or sympathetic inhibitors may be added to diuretic therapy for a more efficacious BP reduction. Combination therapy sometimes has the added advantage of being cost effective. fj­Blockers should be used with caution in insulin­dependent diabetics as hypoglycaemia may be masked or prolonged. Water soluble fj-blockers are better tolerated by obese patients especially when given in combination with a diuretic. Sympathetic inhibitors and vasodilators cause salt and water retention and should be combined with diuretics when used to treat hypertensive diabetics (who may be suffering from renal disease) and patients predisposed to weight gain.

It is important to be aware of individual drug metabolic pathways, any possible drug interactions, and adverse effects when prescribing for hypertensive patients with concomitant disease Ideally, the drug of choice should treat both disease conditions, for example, fj-blockers and calcium antagonists may be used to treat both hypertension and coronary heart disease. The large number of drugs available permits a more selective use of drugs and problem hypertension may be more satisfactorily treated as more is learnt about the new antihypertensive drugs. Saunders E Treatment of problem hypertension Advances In Therapy 5. 103·t t2 Jul·Aug 1988 .. ,.

0156-270389/0128-{)003;OSOI.oo;0 ® ADIS Press INPHARMA" 28 Jan 1989 3