Fig. 1: BIHS adult hypertension pathway therapeutic management.

ABPM ambulatory blood pressure monitoring, ACEi angiotensin converting enzyme inhibitor, ARB angiotensin II receptor blocker, CCB calcium channel blocker, eGFR estimated glomerular filtration rate, HBPM home blood pressure monitoring, SPC single pill combination. *The availability of SPCs is currently limited in the UK and the only triple-component combination contains amlodipine, hydrochlorothiazide and olmesartan. Hydrochlorothiazide has been linked with an increased risk of skin cancer [9] and MHRA recommendations should be followed [10]. a Consider a trial of lifestyle optimisation for 3 months if BP is borderline elevated, especially where there are modifiable lifestyle risk factors including obesity, excess salt or excess alcohol intake. b Check for postural hypotension in those with frailty, aged >80 years, multi-morbidity, type 2 diabetes mellitus, Parkinson’s disease, or symptoms. In individuals with postural hypotension treat to a standing BP target. c See Table 2 for the criteria for routine referrals to a Hypertension Specialist. d See Table 1 for the criteria for emergency/same day referrals to a Hypertension Specialist. e Consider pre-payment certificates, dosette boxes, alarms or electronic reminders. f Encourage lifestyle modifications, including optimising body weight, salt and alcohol intake. Promote smoking cessation to reduce total cardiovascular risk. Re-review other drugs/supplements including: concomitant prescription of combined oral contraceptive pill or implant, hormone substitutes, steroids, NSAIDs, VEGF inhibitors, tyrosine kinase inhibitors (TKIs), tricyclic antidepressants, SSNRIs, dexamphetamine, methylphenidate, herbal supplements, illicit substances and liquorice. Consider co-existing medical conditions (e.g. sleep apnoea, aortic coarctation, chronic kidney disease). g To be avoided in patients with hyperkalaemia or at increased risk of developing hyperkalaemia. May be useful if hypokalaemia or heart failure. Can titrate to 25 or 50 mg. Check electrolytes and creatinine at each titration and ensure potassium remains <5.5 mmol/l (or upper limit of normality according to local laboratories). If feminising effect e.g. gynaecomastia, change to eplerenone at twice the dose, or amiloride. h May cause postural hypotension especially in the frail and older persons (ideally avoid), and in those with multiple co-morbidities. May cause stress incontinence in ~15% women. If a male is on another alpha blocker, e.g. Tamsulosin, then stop and use doxazosin for both hypertension and bladder outflow benefit. Doxazosin XL 4 mg OD or Doxazosin XL 8 mg OD have a smoother pharmacokinetic profile and reduce the incidence of postural hypotension. i Recommended in ischaemic heart disease. Avoid in asthma. May help with anxiety, although propranolol is likely to be more effective. j Consider halving the starting dose in those with heart failure (e.g. lisinopril 5 mg OD). Consider candesartan for dual BP control and migraine prophylaxis.