Hypertension: Pick your pill wisely.

Ain’t gonna talk about diagnosing hypertension, that’s boring stuff. Let’s talk about picking the right pill for your patients, or even yourself (if that ever applies).

Most doctors have their own favorite anti-hypertensive drugs. The common ones are these categories:

  • ACE inhibitors (ACE-i)
  • Angiotension receptor blockers (ARB)
  • Beta blockers
  • Thiazides
  • Calcium channel blockers (CCB)

The less common ones:

  • Alpha blockers
  • Vasodilators
  • Centrally acting agent

My favorite would be the ARBs. As far I’ve seen, they work best in most age groups. The only troublesome thing about this drug is that there’s a chance of causing a rise in the creatinine level as well as a raise in the potassium levels. And patients have to come back, at least once to have their blood taken to ensure it does not happen. And when they do come, it costs them money. And money spent for medical treatment would not be the best topic to talk about. ARBs do not come cheap either. Good ones will dry your bank account up real quick. Ultimately, money becomes the main issue here. It’s not so much about the patient’s kidney function. It’s not about the salts in their body. It’s not about the pain they go through doing blood tests. It’s all about the money. In the end, poorer patients end up not being able to afford these ARBs, end up being disadvantaged. Sad, but that’s how life is. Despite all the issues faced, it’s still one of my favorites.

ACE-i, you say? That’s true. They are in the same group as ARBs but I’ve never enjoyed using them. Of course they are much cheaper, with the same side effects of course. The only downside would be the dry cough it produces, which ARBs don’t. And how common is that? Do try and see, and let me know about it. The hassle of having this cough is rather unpleasant. You present to the doctor for a cough. Some doctors may miss the fact that you’re on ACE-i. You’re exposed to antibiotics. You’re exposed to chest x-rays. You’re exposed to series of blood testing. You’re exposed to public who gets annoyed at you for coughing at their presence.  Bottom line, ACE-i is definitely at the bottom of my anti-hypertensive list.

Ever been on Atenolol? That’s a beta blocker for you. Be it Malaysia or Singapore, it’s one of the most common drug being used to control blood pressure. Some say it’s effective. I say it’s old school. No one should use a beta blocker to control blood pressure as first line. It’s acceptable to use cardio-selective ones such as Bisoprolol or Carvedilol but a big no-no to Atenolol or even Metoprolol, and more so in guys. I know it aggravates asthma, you should know it in undergrad but more importantly, it may break up one’s marriage or even cause much anxiety if he is under-performing in his sex-life. Most Asian men do not share this with you. So please think twice before you’re going to use it. You don’t want to end up destroying one’s life because of a pill you’ve prescribed.

Now, calcium channel blockers are by far my second favorite. One of the safer ones out there. Just be careful when you’re prescribing it to someone with cardiac failure. Otherwise, their side effects are tolerable. Safe for the elderly. Safe for the younger ones. They are relatively cost effective. And patients do not have to return for blood test after starting them on one. Commonly they would get a little form of swelling in their limbs, majority of the time would be the lower limbs but it does affect the upper limbs too, on rare occasions. Easily reversible if stopped.

As for thiazides, I do have to think thrice before starting a patient on one. A cheap alternative. However, as much as I want to use it, I try to stay away from it as it disrupts the salts in the body as well. Low potassium is a very common scenario. Patient end up eating more tablets than they’re supposed to, by taking in Potassium tablets as well. Some may add an ACE-i or an ARB to counter the effect. What’s the point in adding another drug to counter another? It defeats the purpose of having as little medication to take as possible. Minimizing the amount of tablets one should take daily would be the aim to ensure better compliant and control. More drugs to take, more confused one becomes.

To sum things up, ARBs and CCBs are my best picks.

What about the the less common ones? Well, they are called the less common ones for a reason.

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