Ask the Pharmacist

Q: You had mentioned previously that there are many blood-pressure medications available. I noticed that the ones I take are very different than those of my friends. Are there some that are better than others?

A: That is a good question and the answer is, it depends.

There are many medications available that can help reduce your elevated blood pressure. Knowing that, you should not be surprised if you learn that your friends take different medications than you do. Also, your health-care provider may prescribe two or three different medications to help manage your hypertension.

Let’s take a look at the various types of medications you could be prescribed.

Diuretics (fluid pills, water pills), such as Thiazide diuretics (hydrochlorothiazide), Thiazide-like diuretics (chlorthalidone, indapamide), Loop diuretics (furosemide)
 

• These are best taken in the morning due to the increased urination they cause
• They are not the best option for anyone who has challenges getting to the toilet in time or who is at risk of falls
• Thiazide diuretics increase sun sensitivity and some studies found that cumulative hydrochlorothiazide (HCT) doses over 50 grams (gm) can be associated with anywhere from a 30- to 400-per-cent increase in basal cell carcinoma and squamous cell carcinoma. To give you a sense of how long it might take to reach doses of over 50 gm:
  • If your dose is HCT 50 mg daily, that equates to nearly 2.75 years
  • If your dose is HCT 25 mg daily, that equates to nearly 5.5 years
  • If your dose is HCT 12.5mg daily, that equates to nearly 11 years
• You may also be asked to get your blood checked to watch your blood levels of sodium, potassium.

Beta blockers are heart medications that block the effects of adrenaline in your body and help to reduce blood pressure along with your heart rate. Some examples are metoprolol, bisoprolol, atenolol.
 

• Beta blockers should not be chosen as the first medication to treat blood pressure in the elderly
• They are less effective at preventing an initial heart event but once a person has had a heart event, there is compelling evidence showing they are effective at preventing another one
• Beta blockers may worsen fatigue and/or may cause confusion or even depression

Angiotensin Converting Enzyme inhibitors (ACEi), such as ramipril, and Angiotensin Receptor Blockers (ARB), such as telmisartan
 

• Since these two types of blood pressure medications work very similarly, they should never be used together
• Both ACEis and ARBs are quite effective at reducing blood pressure
• There is a greater risk of hyperkalemia (high potassium) and renal (kidney) dysfunction with these medications; it is a good idea to monitor your kidney function and your potassium levels while on these medications
• It is important to know that NSAIDs (anti-inflammatories) can also affect kidney function and if there is any concern for your kidneys, you may be asked to avoid NSAID use

Calcium Channel Blockers (CCBs)
 

• CCBs are comprised of non-dihydropuridines (non-DHP) and include diltiazem and verapamil AND dihydropuridines (DHP), and include amlodipine
• There are some safety considerations associated with CCBs which encourages careful titration of the dose
  • Peripheral edema
  • Arrhythmias
  • Need to be careful combining CCBs with beta blockers
• NonDHPs should not be discouraged to combine with beta blockers because of the profound decreases in heart rate that may occur
• DHPs are less of an issue and might be okay combining with beta blockers

Many people will find they may require multiple blood-pressure lowering medications to effectively reduce their pressure to an acceptable level. This can lead to an extreme pill burden as they may also be dealing with comorbidities (other medical conditions, such as diabetes and high cholesterol).

One way to help manage this overload of medications is to consider combination therapy. There are a few medications available that combine two different classes of blood-pressure medications together, such as combining an ACEi plus diuretic, an ARB plus diuretic, or an ARB plus CCB.

Another example of combination therapy works well if you have both high blood pressure and high cholesterol as there is one combination product that combines a CCB (amlodipine) with a statin (atorvastatin) to help ease the pill burden.

Getting back to the question of which blood-pressure medications are better for you to be taking, depends on your current overall health. If you also have diabetes but do not have chronic kidney disease, you might find yourself taking one or more of thiazide diuretics, ACEi OR ARB or DHP-CCB. However, if you do have signs of chronic kidney disease, the thiazide diuretics would no longer be a great option for you.

Another example is if you also suffer from congestive heart failure. In this scenario, you would likely find yourself taking a loop diuretic (furosemide) or a potassium-sparing diuretic (spironolactone) along with a beta blocker and an ACEi or ARB. These are just some examples to show how the medications can be very different to what others take.

Another question we are often asked, is the best time of day to take blood-pressure medications. There was a study done that showed that those people who took their blood-pressure medications at night had significantly lower rates of heart disease, heart failure and stroke.

The exception to this rule would be diuretics (water or fluid pills), of course, since they are best to be taken in the morning. Otherwise, you might find yourself getting up more frequently than you already do to visit the bathroom because they make you urinate more frequently for several hours after dosing.

Another exception would be people who just cannot remember to take their medications at night. Rather than continually forgetting to take your medications, you would be better off to take them in the morning. 

For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/.