Diagnosis

 

Non-Pharmacological treatment

Lifestyle advice

Offered to all patients with a diagnosis of hypertension at every contact

• Encourage regular exercise
• Weight reduction
• Dietary advice
• Encourage low dietary sodium intake by reducing or substituting sodium salt (avoid salt substitutes containing high levels of potassium)
• Soluble analgesia and indigestion remedies have a high salt content and should also be avoided where possible
• Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure
• Discourage excessive consumption of coffee and other caffeine rich products
• Offer advice and help to smokers to quit smoking through smoking cessation clinic at the surgery or community pharmacy (patient choice)
• Relaxation therapies can reduce blood pressure, however routine provision by primary care is not recommended. If stress is a factor then refer to Time To Talk (TTT)
• Alcohol moderation to within safe limits (up to 14 units per week). Where excessive alcohol intake is suspected to be contributing to high BP, reduction /abstinence should be advised. Refer to CGL if appropriate
• Share link to http://www.bloodpressureuk.org/your-blood-pressure/how-to-lower-your-blood-pressure/

Pharmacological Treatment

 

 

ACE Inhibitors

• Formulary first choice: Ramipril, Lisinopril
• Formulary second choice: Enalapril, Perindopril 

Contraindications

• History of allergy to ACE inhibitors
• History of angioedema (hereditary, idiopathic or associated with previous exposure to an ACE inhibitor)
• Significant bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney
• Concomitant use with aliskiren in patients with diabetes or eGFR < 60 ml/min/1.73m²
• Pregnancy

Cautions

• People of black African or Caribbean origin – may respond less well to ACE inhibitors
• Renal impairment
• Taking diuretics

Dosing for hypertension

• Start with a low dose of angiotensin-converting enzyme (ACE) inhibitor and gradually titrate upwards (usually every 2–4 weeks depending on the drug) until the target blood pressure has been achieved, or until the person has reached the maximum advised or tolerated dose of ACE inhibitor.

• Lower starting doses are required for people who are more prone to the adverse effects of ACE inhibitors (such as elderly, frail, or renally impaired people, or people on low-dose diuretics).

 

ACE inhibitor	Low starting dose	Usual starting dose	Usual maintenance dose	Maximum dose
Ramipril	1.25mg once daily	1.25mg to 2.5mg once daily	2.5mg to 10mg once daily	10mg once daily
Lisinopril	2.5mg once daily	10mg once daily	20mg once daily	80mg once daily
Enalapril	2.5mg once daily	5mg once daily	20mg once daily	40mg once daily
Perindopril	2.5mg once daily	5mg once daily	5mg to 10mg once daily	10mg once daily

*Check manufacturer SPC for dosing in renal impairment

Baseline checks

• Check U&Es, eGFR and BP

• Do not initiate if creatinine > 150umol/l

• Do not initiate if potassium > 5 mmol/l

Ongoing monitoring

• Recheck U&Es and eGFR 1-2 weeks after initiation and after each dose increase
• Check blood pressure 4 weeks after each dose titration
• Thereafter, check U&Es and eGFR annually unless clinical judgement or abnormal blood testing parameters indicate a need for more frequent monitoring. 

Abnormal results

Renal:

• If the eGFR decreases by less than 25%, or serum creatinine increases by less than 30% from baseline do not modify the ACE inhibitor dose and recheck levels in a further 1–2 weeks.

• If eGFR decreases by 25% or more, or serum creatinine increases by 30% or more:

• Discuss blood results with GP (may need to consider renal advice)
• Reduce dose to previously tolerated dose (add alternative antihypertensive medication if required)
• Consider stopping or reducing the dose of other medication (if patient taking) e.g nephrotoxic drugs, diuretics
• Repeat blood test in 5-7 days
• If renal function not returned to baseline stop ACEi and further discuss with GP

Potassium

• If potassium > 5mmol/l:

• Discuss blood result with GP
• Repeat blood test in 5-7 days
• Reduce dose to previously tolerated dose
• Stop or reduce the dose of potassium-sparing diuretics (amiloride, triamterene, spironolactone) or nephrotoxic drugs (such as nonsteroidal anti-inflammatory drugs)

• If potassium ≥ 6mmol/l STOP ACEi. Discuss with GP and repeat blood test same/next day

Sodium:

• If sodium level < 130 mmol/l discuss with GP

 Advice to patient

• Will be introduced at a low dose and increased in stages to achieve blood pressure control.
• More than one type of medicine may be required to control blood pressure.

• Take the first dose in the evening. If the drug is well-tolerated, subsequent doses should be taken in the morning.
• Blood tests for kidney function and levels of the salts in the body are required after each dosage change and are essential to ensure safety of this medication.
• Most common side effect is a cough – can occur at any time but more commonly at early stages of treatment. Cough tends to be dry, irritating, non-productive and often worse at night. (Consider switch to ARB)
• In rare cases allergy to this medication resulting in angio-oedema. Seek urgent medical attention if lip/tongue swelling or difficulty breathing.
• For diabetic patients on treatment - Hypoglycaemic reactions may occur. Blood glucose monitoring is recommended.

Angiotensin Receptor Blocker (ARB)

• Formulary first choice: Losartan
• Formulary second choice: Candesartan (First choice for patients with heart failure)
• Formulary third choice: Valsartan
• Formulary fourth choice: Irbesartan

Contraindications

• History of allergy to ARB
• Significant bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney
• Severe hepatic impairment
• Concomitant use with aliskiren in patients with diabetes or eGFR < 60 ml/min/1.73m²
• Pregnancy

Cautions

• People of black African or Caribbean origin – may respond less well to ARBs

• Renal impairment

• Taking diuretics

Dosing

• Start with a low dose of angiotensin II receptor blocker (ARB) and gradually titrate upwards (usually every 2–4 weeks depending on the drug) until the target blood pressure has been achieved, or until the person has reached the maximum advised or tolerated dose of ACE inhibitor.
• Lower starting doses are required for people who are more prone to the adverse effects of ACE inhibitors (such as elderly, frail, or renally impaired people, or people on low-dose diuretics).

 

ARB	Low starting dose	Usual starting dose	Usual maintenance dose	Maximum dose
Losartan	25mg once daily	50mg once daily	50mg once daily	100mg once daily
Candesartan	4mg once daily	8mg once daily	8mg once daily	32mg once daily
Valsartan	40mg once daily	80mg once daily	80mg to 160mg once daily	320mg once daily
Irbesartan	75mg once daily	150mg once daily	150mg once daily	300mg once daily

*Check manufacturer SPC for dosing in renal impairment

 Baseline checks

• Check U&Es, eGFR and BP
• Do not initiate if creatinine > 150umol/l
• Do not initiate if potassium > 5mmol/l

Ongoing monitoring

• Recheck U&Es and eGFR 1-2 weeks after initiation and after each dose increase
• Check blood pressure 4 weeks after each dose titration
• Thereafter, check U&Es and eGFR annually unless clinical judgement or abnormal blood testing parameters indicate a need for more frequent monitoring. 

Abnormal results

Renal

• If the eGFR decreases by less than 25%, or serum creatinine increases by less than 30% from baseline do not modify the ARB inhibitor dose and recheck levels in a further 1–2 weeks.

• If eGFR decreases by 25% or more, or serum creatinine increases by 30% or more:

• Discuss blood results with GP (may need to consider renal advice)
• Reduce dose to previously tolerated dose (add alternative antihypertensive medication if required)
• Consider stopping or reducing the dose of other medication (if patient taking) e.g nephrotoxic drugs, diuretics
• Repeat blood test in 5-7 days
• If renal function not returned to baseline stop ACEi and further discuss with GP

Potassium:

• If potassium > 5mmol/l:

• Discuss blood result with GP
• Repeat blood test in 5-7 days
• Reduce dose to previously tolerated dose
• Stop or reduce the dose of potassium-sparing diuretics (amiloride, triamterene, spironolactone) or nephrotoxic drugs (such as nonsteroidal anti-inflammatory drugs)

• If potassium ≥ 6mmol/l STOP ARB. Discuss with GP and repeat blood test same/next day

Sodium:

• If sodium level < 130 mmol/l discuss with GP

 Advice to patient

• Will be introduced at a low dose and increased in stages to achieve blood pressure control.

• More than one type of medicine may be required to control blood pressure.

• Take the first dose in the evening. If the drug is well-tolerated, subsequent doses should be taken in the morning.

• Blood tests for kidney function and levels of the salts in the body are required after each dosage change and are essential to ensure safety of this medication.
• Most common side effect is a cough – can occur at any time but more commonly at early stages of treatment. Cough tends to be dry, irritating, non-productive and often worse at night.
• In rare cases allergy to this medication resulting in angio-oedema. Seek urgent medical attention if lip/tongue swelling or difficulty breathing.
• For diabetic patients on treatment - Hypoglycaemic reactions may occur. Blood glucose monitoring is recommended.

 Calcium channel blocker

• Formulary first choice: Amlodipine
• Formulary second choice: Lercanidipine
• (Felodipine preferred in patients with angina) 

Contraindications

• Hypersensitivity to dihydropyridine derivatives or any of the excipients
• Cardiogenic shock
• Severe aortic stenosis
• Haemodynamically unstable heart failure after acute myocardial infarction

Cautions

• Left ventricular systolic dysfunction
• Hepatic impairment
• Limit dose of simvastatin to 20mg in patients taking amlodipine

Dosing

• Start with a low dose of calcium-channel blocker and titrate upwards (if necessary) at intervals of 4 weeks until the target blood pressure has been achieved.

CCB	Usual starting dose	Usual maintenance dose	Maximum dose
Amlodipine	5mg once daily	5mg to 10mg once daily	10mg once daily
Lercanidipine	10mg once daily	10mg once daily	20mg once daily
Felodipine	5mg once daily	5mg to 10 once daily	20mg once daily

Monitoring

• Measure blood pressure 4 weeks after each dose change

 Advice to patient

• Will be introduced at a low dose and increased in stages to achieve blood pressure control.

• More than one type of medicine may be required to control blood pressure.

• Common side effects at start of treatment are headaches and flushing
• Most common side effect is ankle swelling
• Administration with grapefruit juice is not recommended (bioavailability may be increased resulting in increased blood pressure lowering effects)

Thiazide diuretics

• Formulary choice: Indapamide
• (Bendroflumethiazide may be continued if already prescribed)

Contraindications

• Hypersensitivity to indapamide, to other sulphonamides or to any of the excipients
• Severe renal failure, eGFR < 30ml/min
• Hepatic encephalopathy or severe impairment of liver function
• Hypokalaemia
• Pregnancy

Cautions

• Diabetes, gout, and systemic lupus erythematosus — due to risk of exacerbation of these conditions.

• May cause electrolyte imbalance (decreased sodium and potassium)

• Patients treated with cardiac glycosides – risk of hypokalaemia

 Dosing

• Take 2.5mg daily in the morning

Monitoring

• Check renal function and U&Es prior to starting treatment
• Recheck both 1 week later
• Ongoing monitoring required at regular intervals depending on clinical judgement, at least annually
• Discuss with GP if sodium level <130mmol/l
• Discuss with GP if potassium level <3.4mmol/l

 Advice to patient

• Will be used in combination with other medication for blood pressure control
• Is a diuretic (water tablet). Take in the morning to avoid nocturia

Spironolactone

Contraindications

• Addison's disease
• Acute renal insufficiency, significant renal compromise, anuria
• Hyperkalaemia
• Hypersensitivity to spironolactone or any of the ingredients in the product

Cautions

• People with acute porphyrias
• Elderly people
• Hepatic impairment
• Concomitant use of medicinal products known to cause hyperkalaemia

Dosing

• Spironolactone is not currently licensed for the treatment of hypertension, so this is an off-label indication. Obtain and document informed consent.
• Prescribe low-dose spironolactone 25 mg once a day, to be taken with food.
• Upward dose titration is not recommended for the treatment of hypertension alone

Baseline checks

• Check renal function and U&Es prior to initation
• Do not initiate if creatinine > 150 umol/l
• Do not initiate if potassium > 4.5mmol/l

Ongoing monitoring

• Repeat renal function and U&Es test within one month of starting
• Then repeat monitoring monthly for a further 2 months, then every 3 months for 1 year, then every 6 months thereafter or after any dose increase

Abnormal results

Potassium

• If potassium > 5mmol/l stop spironolactone and discuss with GP

Sodium

• If sodium level < 130mmol/l discuss with GP

Advice to patient

• Will be used in combination with other medication for blood pressure control
• Is a diuretic (water tablet). Take in the morning to avoid nocturia
• Regular blood testing to check renal function is required while taking this medication

Alpha-blockers

• Formulary choice: Doxazosin immediate release tablets

 Contraindications

• Patients with a known hypersensitivity to quinazolines (e.g. prazosin, terazosin, doxazosin), or any of the excipients
• Patients with a history of orthostatic hypotension
  • Lactation

 Cautions

• Heart failure
• Postural hypotension
• Impaired hepatic impairment
• Concomitant administration with PDE5-inhibitors (e.g sildenafil) as may lead to symptomatic hypotension. Where possible avoid PDE-5 inhibitor within 6 hours of dose of doxazosin

Dosing

• Initial dose is 1mg daily
• Titrate upwards by doubling the dose every 4 weeks.
• Usual maintenance dosage is 4 mg per day.
• Maximum dosage is 16 mg per day.

Monitoring

• Check BP sitting and standing prior to starting treatment
• Do not initiate/increase dose if postural drop > 20 mmHg
• Reassess response to treatment after at least 4 weeks unless it is necessary to reduce the blood pressure more urgently.

Advice to patient

• Will be introduced at a low dose and increased in stages to achieve blood pressure control.
• More than one type of medicine may be required to control blood pressure.
• Advise to take first dose in the evening, if well tolerated subsequent doses can be taken in the morning
• Postural hypotension may occur particularly when starting treatment or after dose changes. If symptoms occur either discontinue or return to previously tolerated dose
• If patient take PDE-5 inhibitor emphasise risk of hypotension. Suggest avoid PDE-5 inhibitor for first few days after starting/any dose change of doxazosin
• Cataract surgery – ‘Intraoperative Floppy Iris Syndrome’ may lead to increased procedural complications. Current or past use of alpha-1 blockers should be made known to ophthalmic surgeon in advance of surgery

Beta-blockers

• Formulary first choice: Atenolol, Bisoprolol, Metoprolol

Contraindications

• Obstructive airways disease (Asthma and COPD)
• Second or third degree heart block
• Sick sinus syndrome
• Sinus bradycardia
• Severe hypotension
• Uncontrolled heart failure

Cautions

• Diabetes
• First-degree atrioventricular block
• Myasthaenia gravis
• Portal hypertension – due to risk of deteriorating liver function
• Psoriasis

Dosing 

• Atenolol: 25–50 mg daily, higher doses are rarely necessar
• Metoprolol IR: 100 mg daily, increased if necessary to 200 mg daily in 1–2 divided doses, high doses are rarely required; maximum 400 mg per day
• Metoprolol MR: 200 mg once daily
• Bisoprolol - Initially 5 mg once daily, usual maintenance 10 mg once daily; increased if necessary up to 20 mg once daily.

Monitoring

Lung function (in patients with a history of obstructive airway disease)

Audit

1. Run the audit to identify patients who had a high BP but have had no follow up 
2. Send sms to all patients asking them to fill out a 7 day hypertension florey
   1. Any that average noral – send sms to say they are ok and to monitor every 5 years
   2. Any that come back high – book in for Bts and ask them to go to optitians – code hypertensive
   3. If they have organ damage
      • lipids – follow lipd protocol
      • HbA1c – follow diabetes protocol
      • eye damage – refer to duty clinical lead
      • albumin – refer to clinical lead
      • U&E – kidney damage – refer to clinical lead

 

Classification

Stage 1 hypertension	Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
Stage 2 hypertension	Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Severe hypertension	Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.

Measuring Blood Pressure 

Where to measure

1. Home monitoring is encouraged
2. BP Machine in waiting room at all three practices
3. HCA/Clinician BP measurement
4. Pharmacy service

 Blood Pressure by HCA/Clinician

• If the BP is above 140/90, (either systolic, diastolic, or both) check the BP again to confirm.
• If there is a substantial difference between the first 2 readings take a third measurement at the end of the consultation or after a short interval of 5 – 10 minutes, where patient remains seated comfortably.
• The blood pressure should be recorded as the lower of the last 2 readings taken.
• If the BP is > 180/110, urgent (same day) referral /management is needed to identify other co-morbid conditions and the possibility of accelerated hypertension: Refer to DD – send IM
• If BP > 140/90 – 160/110 add to pharmacist hypertension list

White Coat Hypertension

• Persistently elevated clinic BP measurements may indicate white coat hypertension
• Defined as a difference of more than 20/10mmHg between home and clinic readings
• Where suspected consider ABPM or 7 day HBPM

Postural Hypotension

• Symptoms of low blood pressure include dizziness, light-headedness, unsteadiness, fainting, blurred vision and weakness
• If these symptoms occur when the patient changes to a more vertical position e.g standing measure sitting and standing blood pressure
• The patient should stand for at least 1 minute prior to recording
• If systolic BP reading falls by 20mmHg then review medication and measure subsequent blood pressures while standing

When to refer to GP

• If BP is > 180/110, same day referral to duty doctor – by task (for audit trail) and covered by IM
• Symptoms of chest pain, sweating, shortness of breath, wheeze, transient loss of vision, loss of consciousness, fits - Refer to duty doctor
• If an irregular pulse is identified
• Patients with difficult to control BP or co-morbidities that make choice and/or adjustment of medication more complex

Treatment Aims

• Offer antihypertensive treatment to people aged under 80 years with stage 1 hypertension who are found to have target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year CV risk ≥ 20%.
• Offer antihypertensive drug treatment to people of any age with stage 2 hypertension
• For people aged under 40 years with stage 1 hypertension and no evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider seeking specialist evaluation of secondary causes of hypertension

Treatment Targets

Condition	Treatment Target Clinic BP (mmHg)
Essential Hypertension	If < 80 years: ≤ 140/90 (≤ 135/85 ABPM or HBPM)If ≥ 80 years: ≤ 150/90 (≤ 145/85 ABPM or HBPM)
CVD	≤ 140/90
Diabetes	≤ 140/90≤ 130/80 if eye, kidney or cerebrovascular complications
CKD	< 140/90 if ACR < 70mg/mmol< 130/80 if ACR ≥ 70mg/mmol

Hypertension annual review

All patients with diagnosed hypertension should be invited to an annual review:

• Blood pressure check (HBPM if white coat effect)
• Blood test if on ACE or ARB: U&Es, lipids, HbA1c, LFTs
• Urine dipstick test. If proteinuria present consider checking albumin:creatinine ratio
• If not on statin or antiplatelet assess cardiovascular risk using QRISK2/3 assessment tool

Lifestyle advice

Offered to all patients with a diagnosis of hypertension at every contact

• Encourage regular exercise
• Weight reduction
• Dietary advice
• Encourage low dietary sodium intake by reducing or substituting sodium salt (avoid salt substitutes containing high levels of potassium)
• Soluble analgesia and indigestion remedies have a high salt content and should also be avoided where possible
• Do not offer calcium, magnesium or potassium supplements as a method for reducing blood pressure
• Discourage excessive consumption of coffee and other caffeine rich products
• Offer advice and help to smokers to quit smoking through smoking cessation clinic at the surgery or community pharmacy (patient choice)
• Relaxation therapies can reduce blood pressure, however routine provision by primary care is not recommended. If stress is a factor then refer to Time To Talk (TTT)
• Alcohol moderation to within safe limits (up to 14 units per week). Where excessive alcohol intake is suspected to be contributing to high BP, reduction /abstinence should be advised. Refer to CGL if appropriate
• Share link to http://www.bloodpressureuk.org/your-blood-pressure/how-to-lower-your-blood-pressure/

Medication review

• Over the counter medicines
• Avoid NSAIDs and cough/cold remedies or decongestants that may increase blood pressure. Advise patient to always check with the pharmacist before purchasing any OTC medicines
• Consider review of other medicines that may increase blood pressure in particular combined oral contraceptives and HRT, NSAIDs and COXIBs, steroids, fludrocortisone, midodrine, Mirabegron and immunosuppressants.
• Ask patient about any herbal remedies and if check whether these can increase blood pressure