Treating
Hypertension in Haiti- a cardiologist's perspective
Including hypertension RX when laboratory tests are not available.
Medical
problems in Haiti
are no longer primarily the problems of acute trauma, but rather the medical
needs of a displaced population. Many patients are presenting to medical
clinics in Haiti
with blood pressures of 200/115 who have never been on medication or who no
longer have medication available following the earthquake.
Many of the medical clinics
throughout Haiti
are currently without facilities to run blood work, including electrolytes. The
following is a perspective on treating hypertension in
Haiti
by a
United States cardiologist who volunteered in Haiti
the first week of March 2010. I had the privilege of working in
Port-au-Prince
with the Dorsainvil Foundation at one of their clinics during that time.
Tent
city in Port-au-Prince
Table
of Contents:
Top of Page
1.
What medications used for treating
hypertension are particularly cost effective?
2.
What are a few of the medications previously used
for treating hypertension in Haiti?
3.
What is the way to tell a Haitian patient blood pressure results in a way that is understandable to the patient?
4. What are some general
considerations for treating hypertension in Haiti?
5.
What are some specific medications to
consider using, including therapeutic considerations and equivalent dosages of
other medications in the same therapeutic class?
6.
Frequency of medication translated into
English, French, & Kreyol.
7.
What are some cost
effective drug combinations for treating hypertension?
8.
High Blood Pressure Treatment Protocol: If Lab unavailable
9.
High Blood Pressure Treatment Protocol: Lab monitoring available
10.
Why were verapamil, diltiazem, and clonidine not used
as primary drugs in this protocol?
CAVEAT:
All recommendations made here are with the understanding that the final determination of therapy is made by the clinician seeing the patient and based
on their own individual clinical
judgment.
1.
What medications used for treating
hypertension are particularly cost effective for clinics to purchase? (Since
blood pressure medications are continued long term, cost issues become quite
important.)
Medication
dosage
Quantity
Cost to a hospital
pharmacy-USA
amlodipine
10 mg
1000 pills
$25.00
atenolol
50 mg
1000 pills
$20.00
hydrochlorothiazide 25mg
1000 pills
$10.00
(HCTZ)
lisinopril
20mg
1000 pills
$50.00
(amlodipine 2.5˘/pill, atenolol 2˘/pill, HCTZ 1˘/pill, lisinopril 5˘/pill)
Home
2. What are a few of the medications previously used for treating hypertension
in Haiti?
Hydrex is hydrochlorothiazide (HCTZ)
(This same brand name is used for different medications throughout the world.)
Hydrex-terene is HCTZ/triamterene
(often 25mg/50mg)
enalapril (an ACE inhibitor) ,
metoprolol (a beta blocker)
Home
3.
What is the way to tell a Haitian
patient about their blood pressure
results in a way that is understandable to the patient?
Blood pressure values are not recognized by patients in Haiti
if they are told their blood pressure is 152/101. For the Haitian patient, the
blood pressure nomenclature for this blood pressure is 15/10.
Similarly, if a BP
is 178/92, the nomenclature recognized by the non medical Haitian population is
18/9. If a patient is informed that the blood pressure is 178/92 there will be
no comprehension of what is said. If that same patient is told that their blood
pressure is 18/9, the patient may well say on their own, “Oh, that blood
pressure is too high.”
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4. What are some general considerations in treating hypertension in Haiti?
1. All patients should be told to decrease salt intake and increase fruit and vegetable intake, if possible.
2. For patients started on hydrochlorothiazde (HCTZ), advise the following.
-Eat at least one piece of fruit daily:
Either a banana, tomato, or citrus fruit (such as an orange).
(When a daily banana was initially recommended, many of the patients seen did not have access to bananas or did not like bananas, so the recommendation was broadened.)
(HCTZ is an effective BP medication which is a very mild diuretic and causes potassium-K+ loss and hence the above recommendation.)
3. Consider giving each medication in a separate plastic container with a label attached to the outside of the
container detailing medication, dose, and frequency. (Plastic bags may be
used as containers.)
Ask the patient to bring all containers of medication back with them to the clinic approximately 5 days before the medication runs out.
This ensures that the doctors will know what medications the patient has been taking and
be able to give appropriate additional medications.
4. If ˝ pills are used, consider having someone at the clinic split the pill for the patient and place them in the plastic bag or other container to increase compliance. (Though some crumbling of the pills occurs, the expected increase in patient compliance outweighs this concern.) 5.
Tell the patient that if they develop an infectious gastroenteritis with either profuse diarrhea or sustained nausea and vomiting, they should hold the diuretic therapy (HCTZ) and ACE inhibitor therapy (lisinopril), until the gastroenteritis resolves. Other blood pressure medicines may need to be held, but this issue is particularly important with HCTZ
and ACE inhibitors. _
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5.
What are some specific medications to consider
using?
(Includes
therapeutic
considerations and equivalent dosages of other medications in the same
therapeutic class)
Home
Amlodipine
is a calcium channel blocker. There
is no need for laboratory monitoring with amlodipine.
Amlodipine is very similar in effects and side effects to extended release
nifedipine. Both medications are the same type of calcium channel blockers.
Side effects:
-Can cause lower
extremity swelling (noncardiac) in a dose related fashion. A small amount of
swelling is common and acceptable if not bothersome to the patient. Usually,
swelling occurs during the first week. Swelling resolves if the medication is
stopped.
-Can increase heart rate and provoke angina.
Amlodipine 5mg qd is the
therapeutic equivalent to nifedipine
(extended release) 30mg qd. (Amlodipine 10mg qd is the approximate
therapeutic equivalent to nifedipine XR 60mg qd.) Amlodipine and extended
release nifedipine are different medications but with similar efficacy and
similar side effect profiles. The preferred agent is whichever is drug is
cheaper. (Nifedipine that is not an extended release is not an equivalent
agent.) If both drugs are similar in
price, obtain amlodipine, since there are more clinical trials documenting
benefit.
Home
Atenolol
is a beta blocker. There is no need for laboratory
monitoring with beta
blockers.
Atenolol and metoprolol are in the same class of medications with similar
efficacy.
Side effects: Can cause excessively
slow heart rate, fatigue, and bronchospasm (asthma)- usually in individuals who
already have this tendency. If patient has a pulse less than 60 beats per minute, would not
prescribe this type of medication. Side effects of beta blockers are
apparent through either history or physical exam. Beta blockers slow the heart
rate to some degree in all patients and this is an expected effect. Beta
blockers can also cause impotence.
Beta blockers can be less effective for treatment of hypertension in blacks.
However, there is so much mixed ancestry in
Haiti that it is unclear whether this concern has significant general applicability
to Haiti.
Atenolol 50 mg qd is the therapeutic
equivalent of metoprolol 25mg bid.
Atenolol 100mg qd is the therapeutic equivalent of metoprolol 50mg bid. (Atenolol has a
longer half life and is cheaper for an equivalent therapeutic
effect.)
Home
Hydrochlorothiazide
(HCTZ) is a blood pressure medication and a
very mild diuretic. HCTZ can cause low potassium. Infrequently, HCTZ can cause
decrease renal function. Usually, this is not a problem when used in low
dosages. Older patients are more at risk, though HCTZ is usually tolerated even in this
population, at low dosages. HCTZ is ideally used with laboratory monitoring.
HCTZ tends to increase the effectiveness of other blood pressure medication when
used in combination with other medications.
Recommendations: Consider using HCTZ, even
without laboratory, in very low dosages. (HCTZ 12.5mg or ˝ of 25mg pill). The
higher the dosage, the more likely that low potassium will result.
When HCTZ is used, recommend that the patient eat foods high in potassium.
HCTZ/triamterene
tablets would be an option. Pills that can be split (rather than
capsules), which allow for lower dosages of HCTZ to be used, are recommended. (The
potassium losing characteristics of HCTZ are usually only partially made up by
the weaker potassium sparing effects of triamterene.) However, HCTZ/triamterene
combinations are considerably more expensive than HCTZ.
Home
Lisinopril
is an ACE inhibitor. Lisinopril is
ideally used with laboratory monitoring.
Side effects: Can raise potassium levels excessively in some patients.
Lisinopril can cause a significant decrease in renal function in some patients.
Risk for adverse renal effects greatly increases with age. Highest risk
is for a patient with bilateral renal stenosis which most commonly occurs in the
older patient with diffuse atherosclerosis.
Side effects:
Excessively elevated potassium.
Decreased
renal function.
Non productive cough. Occurs in
approximately 1 out of 20 patient and begins 1-2 weeks after starting the
medication. The cough is annoying but will resolve approximately one week
after the medication is stopped.
Not to be used in pregnancy.
Recommendations:
Lisinopril can be considered for patients
less than 55 years of age even if lab
is not available, if needed in addition to other medication to control severe
hypertension. The risks and benefits for each individual patient need to be
considered, but severe hypertension that is not well controlled has major risks.
If
a patient has recently previously taken enalapril without a problem in a lab
monitored setting, then lisinopril can usually be restarted regardless of age.
Lisinopril is in the same class of medication as enalapril.
Lisinopril 10mg qd is the therapeutic equivalent of enalapril 5mg bid. Lisinopril
20mg qd is the therapeutic equivalent of enalapril 10mg bid. (Lisinopril has a
longer duration of action.) Enalapril is equally good for hypertensive control,
but to achieve an equivalent effective dose, the expense of enalapril tends to
be significantly more, at least in the United States.
Captopril is also an ACE inhibitor and has the shortest half life.
Captopril is similarly more expensive than lisinopril, with captopril 25mg bid
being the approximate equivalent of lisinopril 10mg qd.
Home
Cost
effective
combinations of medications for hypertension (when laboratory monitoring
available):
Amlodipine/ HCTZ
Amlodipine/Lisinopril
Lisinopril/HCTZ
Amlodipine/Lisinopril/HCTZ
(A beta
blocker can be used with any of the above combinations.)
Angiotensin
receptor blockers:
As a footnote, there is a good deal of relatively
small amounts of various angiotensin
receptor blockers at some of the
volunteer clinics in
Haiti
(as a result of samples given to doctors that were subsequently brought into
the country).
Angiotensin receptor blockers
have essentially the same effects as ACE inhibitors on the patient in regards to therapeutic effects. Angiotensin receptor blockers also have the same side effect profile except no problem with cough and a somewhat decreased risk of rare allergic
reactions compared to ACE inhibitors.
Currently, there are no generic versions of these in the United States. When they initially become available, these generic versions will tend to be
much more expensive than lisinopril. Except
for using up the samples of angiotensin receptor blockers as
a temporary
equivalent to lisinopril, they do not have much of
a role in Haiti because
of the cost.
In
order to allow the identification of these sample medications that are at some of the
volunteer clinics, the following names are provided.
Brand
names/(generic):
Atacand/(candesartan), Avapro/(irbesartan), Diovan/(valsartan), Micardis/(telmisartan),
Teveten/(eprosartan). (These are often combined with low dose
hydrochlorothiazide--HCTZ.)
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Addendum:
Frequency of Medication
Translation into English, French, & Kreyol
English:
Take one pill a day- qd
French:
Prendre une pilule(comprimé) par jour
Kreyol:
Pran yon grenn chak jou
English:
Take one pill twice a day- bid
French:
Prendre une pilule(comprimé) deux fois par jour
Kreyol:
Pran yon grenn de fwa pa jou
English:
Take one pill three times a day- tid
French:
Prendre une pilule(comprimé) trois fois par jour
Kreyol:
Pran yon grenn twa fwa pa jou
English:
Take one pill four times a day- qid
French: Prendre une pilule(comprimé) quatre fois par jour
Kreyol: Pran yon grenn kat fwa pa jou
Home
Protocols
for Treating the
Hypertensive Patient in
Haiti
There are a number of ways to approach the treatment of the
patient with high blood pressure when laboratory testing is not available. The
following is one approach.
Naturally, the particular circumstances of the individual patient and the
experience and clinical judgment of the individual medical practioner will lead
to modifications of this protocol or even a different treatment protocol
altogether. However, in the hope of providing concrete and usable information to
the volunteer medical health care provider working in Haiti, the following treatment protocol is offered as a potential starting
point.
The medications that are used in this protocol are very
cost effective increasing the feasibility of making a sustainable effort to treat
blood pressure in this setting. (At wholesale prices, the cost
of a 3 drug regimen is 10 cents/day.)
Home
PLEASE READ CAREFULLY:
Prior
to the use of any treatment protocol for hypertension, the medical practioner
should be personally knowledgeable of the side effect profile of every
medication that is prescribed.
The
following protocol is simply an approach to consider, with the final treatment
decision to be made by the medical care provider seeing the individual patient
while taking into account the particular clinical conditions that exist.
HIGH
BLOOD PRESSURE TREATMENT PROTOCOL
WHEN LAB MONITORING NOT AVAILABLE
- If a patient has a contraindication or a significant side effect
develops with a medication, delete that medication from the protocol.
Home
-
The prescribing health care provider must
be personally knowledgeable about the complete side effect profile of every
medication prescribed. Final treatment decisions are to be made by the health
care provider in the context of the particular conditions that exist for the
individual patient.
-
All patients treated for hypertension should be advised to
decrease salt intake and increase fruit and vegetable intake.
-
If the patient develops
profuse diarrhea or sustained nausea and vomiting, hold diuretic (HCTZ) and
ACE inhibitor therapy (lisinopril) until gastroenteritis resolves. (May need to
hold other blood pressure medications as well.)
----------------------------------------------
HTN TREATMENT FLOW CHART- IF NO LAB AVAILABLE:
If systolic BP 140-149 or diastolic BP 90-95:
If
BP:
systolic 140-149
or
diastolic
90-95
|
Advise
diet changes
And
return to clinic in 1 month
|
==============================================
If
P > 80 or angina symptoms:
If
BP:
systolic 150-160
or
diastolic
96-100
|
atenolol1
50mg 1-2 qd (begin with 1 pill qd)
(Use verapamil2 if atenolol contraindicated)
verapamil2 SR 240mg qd |
--------------------------------------------------------------------
If
P ≤ 80 :
If
BP:
systolic
150-160 or
diastolic
96-100
|
amlodipine3
10mg ˝ -
1 pill qd |
=============================================
If P > 80 or angina symptoms
:
If
BP:
systolic >160
or
diastolic
>100
|
atenolol1
50mg 1-2
qd (Use
verapamil2 if atenolol contraindicated.)
After
heart rate slowed, can add:
amlodipine3 10mg ˝ - 1 pill qd
(Can not use amlodipine
if verapamil is being used.)
|
------------------------------------------------------------------------------
If
P ≤ 80
:
If
BP:
systolic >160
or
diastolic
>100
|
amlodipine3
10mg ˝ - 1 pill qd
and
HCTZ4 25mg
˝ pill qd
|
================================================
If 2 medications used with persistent hypertension:
If
on 2 drug regimen and
systolic
BP > 145
or
diastolic
BP
> 95
|
Use
a 3 drug regimen:
amlodipine3 10mg qd
HCTZ4
25mg
˝ qd
atenolol1
50mg qd
|
=================================================
If 3 medications used with persistent hypertension:
If on
3 drug regimen and
systolic ≥ 150
or
diastolic ≥
100
|
Have
patient seen by a practioner experienced in the
treatment of hypertension in order to consider adding: lisinopril5
20mg ˝ -
1 pill qd |
-
Atenolol1
use can be limited by the development of bronchospasm or excessive slowing of
heart rate, particularly if accompanied by lightheadness. (Atenolol always slows
heart rate.) Beta blockers can also can impotence.
Beta blockers
can be less effective for the treatment of hypertension in blacks. However, there is so much mixed ancestry in
Haiti, that it is unclear whether this concern has significant general applicability
to Haiti.
Verapamil2 can not
routinely be combined with atenolol (a beta blocker) or amlodipine. The slow
release formulation of verapamil which is needed for hypertension is relatively
much more expensive than the other medications in this protocol. Verapamil can
cause excessive slowing of heart rate, constipation, and GI upset.
Amlodipine3 can at times
cause the development of increased heart rate and angina.
HCTZ4
(hydrochlorothiazide) use in the unmonitored lab setting should be limited
to a maximum dose of 25mg ˝ pill qd. HCTZ
use should always be accompanied by the advice to eat 1 additional piece of
fruit daily (banana, tomato, or citrus fruit) to minimize potassium loss.
Lisinopril5
in this setting should not be used in patients with cachexia or dehydration because of the increased risk of renal dysfunction. Lisinopril tends to increase
potassium levels. Lisinopril (as well as any other ACE
inhibitor) is not to be used
during pregnancy.
===================================================
===================================================
PLEASE READ CAREFULLY:
Prior
to the use of any treatment protocol for hypertension, the medical practioner
should be personally knowledgeable of the side effect profile of every
medication that is prescribed.
The
following protocol is simply an approach to consider, with the final treatment
decision to be made by the medical care provider seeing the individual patient while
taking into account the particular clinical conditions that exist.
Home
HIGH
BLOOD PRESSURE TREATMENT PROTOCOL
WHEN LAB MONITORING IS AVAILABLE
- If a patient has a contraindication or a significant side effect
develops with a medication, delete that medication from the protocol.
-
The prescribing health care provider must
be personally knowledgeable about the complete side effect profile of every
medication prescribed. Final treatment decisions are to be made by the health
care provider in the context of the particular conditions that exist for the
individual patient.
-
All patients treated for hypertension should be advised to
decrease salt intake and increase fruit and vegetable intake.
-
If the patient develops
profuse diarrhea or sustained nausea and vomiting, hold diuretic (HCTZ) and
ACE inhibitor therapy (lisinopril) until gastroenteritis resolves. (May need to
hold other blood pressure medications as well.)
----------------------------------------------------------------------------
HTN TREATMENT FLOW CHART- LAB MONITORING AVAILABLE:
If systolic BP 140-149 or diastolic BP 90-95:
If
BP:
systolic 140-149
or
diastolic
90-95
|
Advise
diet changes
And return to clinic in
1 month
|
================================================================================
If
P > 80 or angina symptoms:
If
BP:
systolic
150-160 or
diastolic
96-100
|
atenolol1
50mg 1-2 qd (start with 1
pill qd)
(Use
verapamil2 if atenolol contraindicated)
verapamil2 SR
240mg qd |
---------------------------------------------------------------------------------------------------
If
P ≤ 80 and no angina symptoms :
If
BP:
systolic
150-160 or
diastolic
96-100
|
Start** with either:
HCTZ4 25mg ˝ - 1 pill qd
lisinopril5
20mg ˝ - 1 pill qd
amlodipine3
10mg ˝ - 1 pill qd |
===============================================================================
If P > 80 or angina symptoms:
If
BP:
systolic
>160 or
diastolic
>100
|
atenolol1
50mg 1-2 qd
(Use verapamil if atenolol contraindicated)
After heart rate slowed, can add:
amlodipine3 10mg
˝ - 1 pill qd. (Can
not use amlodipine if verapamil used.)
|
---------------------------------------
If: P
≤ 80
If
BP:
systolic
>160 or
diastolic >100
|
amlodipine3
10mg ˝ - 1 pill qd
and
HCTZ4 25mg
˝ - 1 pill qd
or
lisinopril5 20mg qd and HCTZ 25mg ˝ - 1 qd
or
lisinopril5 20mg qd and amlodipine 10mg ˝ - 1 qd
|
====================================================
If:
BP remains high on a 2 drug regimen:
If
on 2 drug regimen and
systolic
BP > 145
or
diastolic
BP > 95
|
Use
a 3 drug regimen for difficult to control HTN:
amlodipine3 10mg qd
lisinopril5 20mg qd
HCTZ4 25mg qd
A fourth medication can subsequently be added if needed:
atenolol1 50mg 1-2 pills qd |
------
Atenolol1 use can be limited by the development of
bronchospasm or excessive slowing of heart rate, particularly if accompanied by
lightheadness. (Atenolol always slows heart rate.) Beta blockers can also cause
impotence.
Beta blockers can be less effective for the treatment of hypertension in blacks.
However, there is so much mixed ancestry in
Haiti, that it is unclear whether this concern has significant general applicability
to Haiti.
Verapamil2 can not routinely be combined with atenolol (a
beta blocker) or amlodipine. The slow release formulation of verapamil which is
needed for hypertension is relatively much
more expensive than the other medications in this protocol. Verapamil
can cause excessive slowing of heart rate, constipation, and GI upset.
Amlodipine3 can at times cause the development of
increased heart rate and angina.
HCTZ4 (hydrochlorothiazide) use in the unmonitored lab setting should be limited to a maximum dose of 25mg ˝ pill qd. HCTZ use should always be accompanied by the advice to eat 1 additional piece of fruit daily (banana, tomato, or citrus fruit) to minimize potassium loss.
Lisinopril5 in this setting should not be used in
patients with dehydration because of
the increased risk of renal dysfunction. Lisinopril tends to increase potassium
levels. Lisinopril (as well as any other ACE inhibitor) is not to be used
during pregnancy.
** Concerning the initial treatment of hypertension**
Many advocate routinely using a diuretic as the initial drug of choice in the treatment of hypertension on the basis of the
ALLHAT trial and that trial’s effect on subsequent meta analyses. However, this appears to be an inappropriate overgeneralization of the ALLHAT trial
results. The ALLHAT trial had particular requirements for treatment protocols that
do not mimic routine clinical practice. These include the prohibition of using lisinopril (an ACE inhibitor) with a diuretic as a second agent, the prohibition of using amlodipine with a diuretic as a second agent, and the prohibition from using amlodipine in combination with lisinopril which is a synergistic combination frequently used in clinical practice.
For further details see: http://www.improvingmedicalstatistics.com/ALLHAT/Critique.htm
In fact, the subsequent ACCOMPLISH trial found that the combination of an ACE inhibitor with amlodipine compared favorably with HCTZ for the initial treatment of hypertension.
For details: http://content.nejm.org/cgi/content/short/359/23/2417
---------------------------
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Why were verapamil, diltiazem, and clonidine not recommended as primary drugs in
this treatment protocol for hypertension?
They were not included for reasons of cost, compliance, and compatibility
with other agents. It is worthy
to note that short acting generic drugs that require a long acting formulation
are almost always significantly more expensive than generic drugs in the same
class of medication with an intrinsically long half life.
VERAPAMIL
and DILTIAZEM are both calcium channel blockers, but affect the body
so differently compared to amlodipine or nifedipine, that it is best to consider
these drugs as being functionally a completely different type of medication.
The reasons for not including these medications as primary medications in this
protocol will be detailed with verapamil.
Verapamil
is an option for treatment of a patient in a setting without laboratory
monitoring.
VERAPAMIL is useful for the treatment of
the patient with hypertension with an elevated heart rate or in the presence of
angina when beta blockers can not be used.
Verapamil can also be useful for
patients with hypertension and palpitations resulting from SVT (supraventricular
tachycardia) or atrial ectopy.
However, it is not used more widely
in this protocol for the following reasons:
1.
Verapamil slows heart rate, though less than a beta blocker. Verapamil should not used in combination with a beta blocker for the treatment of hypertension in this setting (Verapamil can be used in combination with a beta blocker in a closely monitored situation by an experienced clinician for a condition such as angina.)
2. Verapamil can not routinely be used with amlodipine or nifedipine because they are in the same class of medications (even though they have different
effects).
3. Verapamil formulations which are not long acting need to be given as a bid or tid dosage which decreases compliance. Long acting verapamil is the preferred agent for the treatment of
hypertension.
4. Long acting verapamil is much more expensive than amlodipine.
DILTIAZEM
is not useful as a primary drug in this protocol for similar reasons. In
addition, long acting verapamil has much better evidence from clinical trials
compared to diltiazem that it favorably affects clinical endpoints when used for
hypertension.
CLONIDINE:
Clonidine is potentially useful as a
drug for hypertension in the unmonitored setting. Side effects of dry mouth,
fatigue, and postural hypotension can all be assessed without any laboratory
monitoring which is a beneficial feature. A
reasonable case can be made for including this medication for the treatment of
hypertension with or without laboratory monitoring.
However,
clonidine was not included as an initial drug of choice in this protocol because
of the following.
1.
The bothersome side effects of postural hypotension, dry mouth, and fatigue are common with this medication. If side effects occur early on in treatment, the patient will be less likely to continue with any blood pressure treatment or even return for follow up, particularly when there is not a broad public campaign to increase the awareness of the need for maintaining a good blood pressure.
2. Clonidine is short acting and optimally given on a bid or tid schedule. This dosing frequency will lead to decreased patient compliance.
3. Long acting transdermal formulations of clonidine are available which significantly decrease the frequency of annoying side effects to the patient, but these are much more expensive and not suitable in this setting for that reason.
4. For resistant hypertension, not responsive to other agents, a trial of clonidine
with an initial dose of 0.1-0.2mg qhs or clonidine 0.1mg bid added to other medications is a reasonable option.
--------------------------------------------------------------------------------------
I
hope this information
will be helpful in the care of the Haitian
population,
as well as volunteer medical efforts in 3rd world countries, where cost
effective treatment is essential.
E. Roehm, M.D.
HypertensionRxHaiti.com
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