Which BP Drug Works Best for You?

Chances are good you are taking a blood pressure (BP) medication. That’s because guidelines from the American College of Cardiology (ACC) consider anything greater than 120/80 “elevated” blood pressure. According to this metric, more than 116 million adults have hypertension. Put another way, that’s about half of all grown-ups. If you are taking a BP drug, which one is right for you? You may be surprised to learn that there is significant variability in response to anti-hypertensive medications. What’s best for one person may not work so well for another.

How Does Your Doctor Determine which BP Drug to Prescribe?

If your blood pressure readings are around 133/84, the chances are very good that your doctor, nurse practitioner (NP) or physician associate (PA) will recommend weight loss or exercise to bring your blood pressure down. If that doesn’t get you below 120/80 you are likely to receive a prescription. But which BP drug will you get?

The most prescribed anti-hypertensive medications are in this order:

1. Lisinopril
2. Amlodipine
3. Metoprolol
4. Losartan
5. Hydrochlorothiazide (HCTZ)
6. Carvedilol
7. Atenolol
8. Spironolactone
9. Propranolol
10. Clonidine

How does your health care professional decide which one you should take?

As far as we can tell, there is no easy way for your prescriber to determine which BP drug will work best for you. If a doctor is in the habit of prescribing lisinopril or amlodipine, that is what you will get. If she likes to write prescriptions for HCTZ or losartan, that is what the pharmacy will dispense. Does it matter?

Why the Choice of BP Drug Matters!

Until this week, most health professionals could not tell you if the blood pressure medication they prescribe matters. If a low dose doesn’t do the job, they likely will up the dose. If one pill doesn’t get you under the guideline target, another medication will be added. And another.

Everything changed this week because of a Swedish study published in JAMA (April 11, 2023). To sum up what they found: One size (or one BP drug) does not fit all!

The Objective of this study was, in the authors’ own words:

“To investigate and quantify the potential for targeting specific drugs to specific individuals to maximize blood pressure effects.”

The Findings of the research:

“In this randomized, double-blind, repeated crossover trial, the blood pressure response to treatments varied substantially between individuals.”

The Meaning of the study:

“There is heterogeneity in blood pressure response to drug therapy for hypertension, of a magnitude that warrants further research.”

OK, that’s stuffy doctorspeak. What it means is that people with high blood pressure differ substantially in how they react to a blood pressure medication. Some people do better on an ACEi (angiotensin converting enzyme inhibitor) like lisinopril. Others respond well to a diuretic like hydrochlorothiazide or a calcium channel blocker such as amlodipine.

The bottom line: It matters which BP drug your doctor prescribes.

What They Did:

The researchers recruited 270 men and women with hypertension. Each participant received four different types of blood pressure-lowering medications over 7- to 9-week treatment periods. One of the medications was lisinopril, known as an ACE inhibitor. The volunteers also tested a diuretic called hydrochlorothiazide. A calcium channel blocker called amlodipine was also included in this cross-over test. Finally, an angiotensin-receptor blocker or ARB called candesartan was part of the 4-drug test protocol.

During each treatment period the participants were monitored with a 24-hour ambulatory blood pressure device. It gathered measurements every 20 minutes during daytime and every hour at night.

Which Drugs Did Best:

“The selected treatment doses were on average not equipotent, with participants having higher BP when taking hydrochlorothiazide than when taking other treatments, when taking amlodipine compared with lisinopril, and when taking candesartan compared with lisinopril.”

This does not mean that you would do best on lisinopril. The authors repeatedly point out that:

“This study provided evidence that widely used antihypertensive drugs vary in effectiveness between individuals, with potential for greater BP reductions with personalized targeting of therapy.”

“Personalized treatment” is the take home message from this research! What does it mean?

Many health professionals increase the dose if a BP drug doesn’t accomplish their targeted goal. If that doesn’t work, they frequently add a second or a third BP drug. The authors of this study state that:

“personalized targeting of therapy”

is twice as effective as

“doubling the dose of a first BP-lowering drug, and more than half that of adding a second drug on average.”

They go on to add that:

“The potential for large BP-lowering gains from personalizing antihypertensive therapy highlights the need for a mechanism that can be used to identify which individuals will benefit most from which treatments.”

And There’s the Rub:

Currently, health care professionals do not know which BP drug will work best for you. It is trial and error. Someday, there may be a genetic test that will reveal the ideal medication for a specific patient. That day has not yet arrived.

What can you do, then? The researchers offer a suggestion. It boils down to trial and error! Specifically, they describe “…directly measuring the individual’s response to a series of treatments to ascertain which is most effective.” In other words, trial and error.

Most health care professionals don’t have the time and patience to try a “series of treatments to ascertain which is most effective.” That’s a shame, though. Wouldn’t you rather take the most effective BP drug for you rather than increasing the dose or adding one or two more meds?

What About BP Drug Side Effects?

Let’s not forget adverse reactions to blood pressure medications. Not everyone can tolerate lisinopril or amlodipine. Others may experience complications from a “safe” diuretic like hydrochlorothiazide.

We have written extensively about blood pressure treatment. Older people may be especially vulnerable to side effects such as dizziness. You can read about overtreatment at this link.

Learn about amlodipine (Norvasc) side effects at this link.

HCTZ is found in many combination anti-hypertensive medications. You can learn more about potential complications with this diuretic at this link.

The most popular BP drug in the pharmacy is lisinopril. Here are some links you may find helpful:

Lisinopril Side Effects Can Be Life Threatening: Beware Angioedema and ACE Inhibitors!

and

Why Don’t Doctors Recognize Lisinopril Cough?

Learn More:

If you would like to learn more about nondrug approaches to blood pressure management, here is a link to our eGuide to Blood Pressure Solutions. This online resource can be found under the Health eGuides tab.

Please share your own experience with blood pressure medications in the comment section below.