Many people need more than one medicine to reach their blood pressure goal, and that is normal. Two medicines at moderate doses usually work better, with fewer side effects, than one medicine pushed to its maximum.
The main first-line medicines
- ACE inhibitors such as lisinopril, and ARBs such as losartan, which also protect the kidneys
- Calcium channel blockers such as amlodipine
- Thiazide-type diuretics such as chlorthalidone and hydrochlorothiazide
Common combinations
If lisinopril or losartan is not enough, adding amlodipine or a thiazide is a standard next step, and many people take two in a single combination pill. If amlodipine is not enough, adding lisinopril, losartan or a thiazide is common. An ACE inhibitor and an ARB should not be taken together.
Safety points
- ACE inhibitors and ARBs must not be used in pregnancy; tell us right away if you are pregnant or planning to be
- Swelling of the lips, tongue, face or throat on an ACE inhibitor is an emergency; call 911
- If your blood pressure is 180/120 or higher with chest pain, shortness of breath, severe headache, vision changes, weakness or confusion, call 911; if it is that high without symptoms, recheck in five minutes and call us the same day
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Where beta blockers fit
Beta blockers such as metoprolol are not first-line for most people with uncomplicated high blood pressure. They are the right choice after a heart attack, with heart failure or with certain heart rhythms. Propranolol is sometimes used for physical symptoms of situational or performance anxiety, such as a racing heart before a presentation, which is a different job than daily blood pressure control.
Still high on three medicines?
Blood pressure that stays high on three medicines, including a diuretic, is called resistant hypertension. Before adding more, we check that the readings are accurate at home, that doses are taken as planned, and for hidden causes such as sleep apnea, high sodium intake, alcohol, pain relievers like ibuprofen, or a hormone condition called primary aldosteronism. Spironolactone is a well-studied fourth medicine when needed.
Get help from Hope Integrative Medicine
If your blood pressure is still above goal, we can review your home readings, your medicines and the next step. Our primary care team in West Ashley sees patients in person and by telehealth across South Carolina, and new patients are often able to be scheduled within a week of requesting an appointment. Request an appointment.
This article is general health information and does not replace advice from your own provider. Never start, stop or change a medication without talking with your prescriber.
Frequently Asked Questions
Yes. Lisinopril with amlodipine is a common, well-studied combination, and it is available as a single combination pill. Two medicines at moderate doses often work better with fewer side effects than one at the maximum dose.
Generally no. An ACE inhibitor such as lisinopril and an ARB such as losartan should not be combined, because together they raise the risk of kidney problems and high potassium without better protection.
Beta blockers such as metoprolol are not first-line for most people with uncomplicated high blood pressure. They are the right choice after a heart attack, with heart failure or with certain heart rhythms.