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 taking into account the particular clinical conditions that exist.  

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 taking into account the particular clinical conditions that exist.  

TREATMENT PROTOCOL FOR HYPERTENSION
WHEN LAB MONITORING IS AVAILABLE     Home    Top of Page

      -     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.)
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   HTN TREATMENT FLOW CHART- IF LAB MONITORING AVAILABLE:

    If systolic BP 140-149  or diastolic BP 90-95:

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         If  P > 80 or angina symptoms:

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         If  P ≤ 80 and no angina symptoms :

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        If  P > 80 or angina symptoms:

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        If:  P ≤ 80

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        If:  BP remains high on a 2 drug regimen:  

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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 significahnt 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 ½ 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 inhibitors) are 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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Cost Effective Medication for Treating Hypertension:

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)  
    

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