Hypertension: Medication Treatment
Guest: Dr. Perry Halushka – College of Graduate Studies
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing Dr. Perry Halushka who is Professor of Medicine and Pharmacology here at the Medical University of South Carolina. Dr. Halushka, let’s talk now about medication treatment for hypertension. In another podcast we talked about lifestyle modification, which is also important, but let’s turn now to the meds. There are a lot of different medications. Where do you start? How do you begin to think about the choices when you’re taking care of a patient with hypertension?
Dr. Perry Halushka: Well, one of the medicines that we almost invariably start patients on is hydrochlorothiazide (HCTZ) and that’s a diuretic. What we know is, first of all, it’s very safe. It’s very effective and it’s been around for well over 50 years. And many studies, now, have shown that it will, indeed, not only lower blood pressure but synergize, or be additive, with other high blood pressure medicine. So the first line of therapy, we still feel today, is a diuretic.
Dr. Linda Austin: What does a diuretic do?
Dr. Perry Halushka: A diuretic does two things. First of all, it increases the amount of sodium that you actually excrete out of the body. And we said before, we know a lot of patients are sensitive to sodium, or salt, so that helps lower blood pressure. And along with the sodium being excreted in the urine, water goes along as well,
so there’s a certain decrease in the total circulating volume of the patient. So that combination of increasing the amount of sodium that you excrete and the water that follows tends to lower blood pressure.
Dr. Linda Austin: And hydrochlorothiazide is a cheap drug, isn’t it?
Dr. Perry Halushka: It is about the cheapest drug you could purchase. I like to say inexpensive though because it’s very effective.
Dr. Linda Austin: So that’s the first treatment. Is hydrochlorothiazide alone ever sufficient, or do you usually have to go to a second medication?
Dr. Perry Halushka: In many patients, interestingly, that is sufficient, especially those with only mild elevations in their blood pressure. And if they combine that with the lifestyle modification we talked about, for many patients, that is actually sufficient.
Dr. Linda Austin: If it is not sufficient, what is your second line?
Dr. Perry Halushka: So, second line, we have several options today. First of all, one class of drugs, called ACE inhibitors, which have been around for a reasonable period of time now, we find not only effectively lower blood pressure but also protect the heart and the kidneys. So, again, it’s not just the lowering of the blood pressure, but to have additive protective effects for the heart and the kidney.
Another class of drugs very similar to the ACE inhibitors is the angiotensin receptor blockers (ARBs), which also have very similar effects, lower blood pressure, protect the heart and protect the kidney.
An additional class of drugs that have also been around for longer than the ACE inhibitors and the angiotensin receptor blockers are beta blockers. Beta blockers are also very effective in lowering blood pressure and protect the heart in particular. For patients that have had a previous heart attack, we invariably start them on a beta blocker and/or an ACE inhibitor to not only, again, lower the blood pressure but to protect the heart.
And there’s one other very important class of antihypertensive medicines and those are the calcium channel blockers. They, too, are very effective and they work predominantly by relaxing the blood vessels and lowering blood pressure. All are very effective drugs and the most important thing is rarely do you see a significant side effect with them.
Dr. Linda Austin: You know, Perry, in my field, psychiatry, it used to be a no-no to combine medications. Now we know that sometimes you can use lower doses of medications and not have side effects by combining medications. Is that true, also, in the treatment of hypertension?
Dr. Perry Halushka: That is true. Again, it gets back to the use of the hydrochlorothiazide as the first-line agent and so, invariably, you’ll see patients in the combination of hydrochlorothiazide with an ACE inhibitor, an angiotensin receptor blocker, calcium channel blocker, beta blocker. That combination is very commonly used and very effective.
Dr. Linda Austin: I hear men, in particular, are concerned about impotence as a side effect. It seems like that is the most dreaded side effect of all. Can you comment on that? Is that really such a problem?
Dr. Perry Halushka: It is with some medications that interfere directly with the nervous system. The medications that I first mentioned do not do that. On the other hand, some men who have significant problems with hardening of the arteries, when you start to lower the blood pressure, a secondary, unwanted side effect is actually impotence. But that’s not a direct effect of the blood pressure medicine. That’s because you’ve now lowered the blood pressure below some critical level to perfuse what we call the pelvic region. The good thing though is this can easily be taken care of with such drugs as Viagra, for example.
Dr. Linda Austin: So that is the good news.
Dr. Perry Halushka: That is the good news. But let me just throw a caution in. You should never use Viagra if, in fact, you’re also taking nitrates. Many patients who have had high blood pressure and have had a heart attack are taking nitrates and, in that setting, they should never use Viagra.
Dr. Linda Austin: So we need to underline that you need to talk to your doctor about this. Don’t just take your brother-in-law’s Viagra.
Dr. Perry Halushka: I absolutely agree with that. Indeed, I think all the advice we’re giving today should be discussed with your physician who knows your history best.
Dr. Linda Austin: Absolutely. And I think it’s so important to remember that there are side effects to not taking medication. And with hypertension, it’s a possibility of stroke or heart attack, which is obviously, catastrophic.
Dr. Perry Halushka: I completely agree with you. Indeed, I think the number one problem we still have today is that there are many people out there who are not being adequately treated, patients who deny that they have a problem, and to me, that’s unfortunate because we can help all these people. And the side effects, as I said, are really minimal, and the benefits clearly outweigh any risk that people want to talk about.
Dr. Linda Austin: Dr. Halushka, thank you so much.
Dr. Perry Halushka: You’re welcome.
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