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Why are there so many types of blood pressure medication?

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People with serious high blood pressure often end up taking multiple medications at once. Is that really necessary?
Written by Leslie Goldman
Updated on October 15, 2021

Treating high blood pressure can require a little art along with a whole lot of science. That’s because doctors consider many factors when creating your treatment plan.

They’ll look at your other conditions and the medications you take for them. They’ll also factor in your lifestyle and whether your blood pressure is just a little high or extremely elevated. With many variables at play, high blood pressure is complicated — and so is treating it.

You might not respond to medication the same way another person does. For most people, doctors will use multiple medications to come up with a customized treatment plan. And bringing your pressure down with minimal side effects may require a combination of medications and a bit of trial and error to dial them in correctly.

To make sense of this, we spoke to Eric MacLaughlin, PharmD. He’s the chair of the department of pharmacy practice at the Texas Tech University Health Sciences Center’s Jerry H. Hodge School of Pharmacy in Lubbock, Texas. Here’s how he explains the world of blood pressure medication.

And whether you’re new to blood pressure medication or you’ve been treating the condition for a while, Optum Perks can help. Download our app to search for discounts right from your mobile phone.

What are the most common blood pressure medications?

MacLaughlin: There are 4 main choices, or what we call first-line agents. They include:

  • Angiotensin-converting enzyme inhibitors (ACE inhibitors)
  • Angiotensin receptor blockers (ARBs)
  • Calcium channel blockers
  • Diuretics

These medications all lower your blood pressure. That’s an important step in reducing your risk for heart attack and stroke. But they all work in different ways. Depending on your other health conditions, your doctor or pharmacist may prefer a certain drug class over another.

Outside the big 4, your doctor might prescribe other medications. There are beta blockers, alpha blockers, central agonists and more. These medications are not usually recommended as first-line treatments. But doctors may prescribe them based on a patient’s special needs or other conditions.

Often it takes 2 or more medications to get a patient’s blood pressure under control. [Learn more about the causes and symptoms of high blood pressure.]

Let’s review the big 4, starting with diuretics. When are they prescribed?

MacLaughlin: You may initially be prescribed a diuretic if you have stage 1 high blood pressure. This is a milder case. It means your systolic blood pressure — the top number in your reading — is between 130 and 139, or your diastolic blood pressure — the bottom number — is between 80 and 89.

Diuretics [often called water pills] cause you to urinate more, which helps your body get rid of water and extra sodium, or salt. [Salt can raise blood pressure.] Diuretics also help to relax blood vessels throughout the body, which further reduces blood pressure. They were the first medications to show that lowering blood pressure prevents heart attacks, strokes and death. And they are commonly included in most combination medication products.

When would a doctor prescribe an ARB or an ACE inhibitor?

MacLaughlin: For more serious cases of high blood pressure, your doctor might prescribe 2 medications to work together, usually an ARB or an ACE inhibitor with a diuretic or calcium channel blocker. ACE inhibitors and ARBs both prevent the body from creating or using angiotensin II, a naturally occurring chemical that narrows blood vessels. Like a hose, if you narrow the blood vessel, that will increase the pressure.

ACE inhibitors and ARBs also decrease a hormone called aldosterone, which causes your body to retain sodium and water. (ACE inhibitors and ARBs are good to use in combination with diuretics and calcium channel blockers, but they should never be used together.)

What about calcium channel blockers?

MacLaughlin: Calcium channel blockers are another option for cases of high blood pressure. They cause blood vessels to dilate, or widen. They do this not by targeting angiotensin II but by affecting how calcium works in the heart and arteries.

Calcium channel blockers are often given to patients with chest pain due to poor cardiac blood flow. This condition is called angina. They can be used solo or with an ACE inhibitor or an ARB.

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Are people usually on these medications forever? Is it possible to get off of them?

MacLaughlin: They’re all used long term, perhaps even for life. The vast majority of patients will need 2 or more blood pressure medications, either in combination or by adding 1 on when a single drug isn’t working. The goal is to lower your blood pressure to less than 130/80.

All blood pressure medications are meant to be used in combination with heart-healthy lifestyle changes such as a low-sodium diet, exercise and weight loss if appropriate. The DASH diet (dietary approaches to stop hypertension), which is low in sodium and high in fruits and vegetables, is particularly helpful in lowering blood pressure. [Here are more healthy eating tips you can try.]

If you’re interested in getting off blood pressure medications, focusing on changes such as these and achieving a healthy weight may help. But it requires hard work and dedication. That said, it’s doable — I had a patient who was taking 3 or 4 blood pressure medications. He started an exercise routine, lost 60 pounds and was able to cut back to just 1. His blood pressure was actually falling a bit too low, which proves how powerful a combination of medication and lifestyle changes can be.

For patients with severe obesity as well as high blood pressure, bariatric surgery may also be an option.

[Recommended reading: 16 little ways to lower your blood pressure.]

Are there any side effects people should be aware of?

MacLaughlin: ARBs are the least likely to cause side effects. ACE inhibitors, however, can cause a dry cough in up to 20% of people. Rarely, some people may have an allergic reaction to an ACE inhibitor, including swelling of the lips and tongue.

Diuretics may cause fatigue, lightheadedness or muscle cramps. With ACE inhibitors, ARBs and diuretics, your doctor will want to monitor electrolytes and kidney function. Calcium channel blockers can cause swelling in the legs and ankles, constipation, lightheadedness or slow heart rate.

All blood pressure medications can cause dizziness or lightheadedness, usually if the blood pressure drops too low. So monitoring blood pressure at home and routine follow-up visits are important.

When you pick up your medication, you should ask your pharmacist about possible side effects. That way you’ll know what to expect.

Here’s something else you should do while picking up your medication: Use Optum Perks to see if you can score an immediate discount. Simply download our discount card and show it to the pharmacist.

Additional sources
Tips for taking diuretic medications:
Harvard Health
Background on calcium channel blockers: Kaiser Permanente
Understanding ACE inhibitors: Mayo Clinic
Understanding ARBs: British Heart Foundation