Best BP drug depends on the patient

Dear Dr. Roach: I’m trying to find the best high blood pressure drug with the least side effects for a Hispanic male, 77 years old, with swollen ankles at the end of the day and readings of 160/76 with a pulse of 64.

Of all the drugs in the market for treating high blood pressure, which one is the best with the least side effects?

N.V.

Answer: There’s no single answer to your question. It depends on the person and their other medical conditions. Even then, there is often some trial and error. For most people who find that non-medication therapy has been inadequate to control blood pressure, we seek a regimen that gets the blood pressure down to the goal with minimal or no side effects.

Your blood pressure is elevated only on the top number, the systolic number. This is common in older people. There are three classes of drugs that are recommended in this situation as first-line treatment: thiazide-type diuretics, calcium blockers and an ACE inhibitor or ARB.

Thiazide diuretics, like HCTZ or chlorthalidone, are very old and inexpensive treatments that have been proven to reduce the risk of stroke in older people with elevated systolic pressure. Unfortunately, they often have only a modest reduction in blood pressure, and your systolic pressure is at least 20 points higher than is ideal, so a thiazide alone is unlikely to be effective enough.

Calcium blockers are much more potent agents, but the most commonly used ones, like amlodipine (Norvasc), often cause ankle swelling. This can be treated by support stockings.

ACE inhibitors (like lisinopril) and ARBs (like telmisartan) generally have very few side effects. ACE inhibitors cause cough occasionally; ARBs almost never do.

Often, in terms of blood pressure reduction and freedom from side effects, a combination of drugs is better than the highest possible dose of just one.

The best data show that it’s getting the blood pressure under control, not the choice of the agents, that best correlates with effectiveness. Choosing a medicine that is effective with no or almost no side effects is the goal. The choice varies by person.