Combination Treatment for Hypertension

Medically Reviewed by Poonam Sachdev on April 30, 2022
Written by Debra Fulghum Bruce, PhD
4 min read

Having blood pressure problems? If one medicine can't lower your blood pressure, your doctor may try combination treatment for hypertension.

Studies show that many people get better control of blood pressure with combination treatment than with one drug.

There are many medications that are used in combination to help control high blood pressure. The goal is clear: control hypertension and you can lower your risk of heart disease.

Combination treatment means another class of blood pressure medication is added to the first drug to increase effectiveness.

Many people with mild high blood pressure respond to one medication. It may take a few tries to find the most effective drug.

However, sometimes one drug cannot control high blood pressure. The doctor may increase the dose or change the medication, yet the blood pressure stays high. That's when a second drug may be added.

Sometimes, patients with higher blood pressure need combination treatment -- even initially -- to bring it to a normal range.

Combination treatment for hypertension is individualized. It gives the best possible control of blood pressure with the fewest side effects.

Also, combination treatment may cost less. There may be less frequent doctor visits as the drug combination effectively manages the hypertension.

Different combinations of drugs in varying dosages are used to treat hypertension. Sometimes, using lower doses of one or more drugs in combination can minimize side effects.

Thiazide diuretics may be used alone to treat hypertension. Low-dose diuretics, though, can also be used with other medications such as beta-blockers.

When used in a drug combination, the diuretic has fewer side effects. It also boosts the blood-pressure-lowering effect of the other medication.

Diuretics are added to other blood pressure medications. For instance, if the person with high blood pressure also retains fluid, a diuretic may be added.

ACE inhibitors or angiotensin receptor blockers are often effective when combined with other classes of medications.

Sometimes, a beta-blocker is combined with an alpha-blocker. This may be useful for men who have hypertension and an enlarged prostate. The alpha-blocker may help both problems at the same time.

Other combinations may include an ACE inhibitor with a thiazide diuretic. Sometimes, an angiotensin II receptor antagonist is combined with a diuretic. Or an ACE inhibitor may be combined with a calcium channel blocker.

Your doctor will prescribe combination treatment cautiously. For instance, if both drugs lower the heart rate, your doctor will monitor you closely. This will keep you from having an excessively slow pulse (called bradycardia).

If you have asthma, your doctor will avoid using drugs that could cause asthma-like symptoms. Trust your doctor to prescribe the most effective treatment with your health in mind.

The main blood pressure drug classes include:

  • Thiazide diuretics: Diuretics remove salt and excess water (fluid) from the body.
  • Angiotensin converting enzyme (ACE) inhibitors: ACE inhibitors are often used in people who have diabetes or heart disease. They help lower blood pressure by inhibiting the production of angiotensin in the body. Angiotensin is a hormone that causes blood vessels to constrict which can lead to increased blood pressure.
  • Angiotensin II receptor blockers (ARBs): The ARBs block the effects of angiotensin.
  • Calcium channel blockers:Calcium channel blockers help lower blood pressure, slow the pulse, and treat arrhythmias (abnormal heart rhythms). Calcium channel blockers can also be used to treat angina (chest pain) and relax the heart muscle.
  • Beta-blockers: Beta-blockers slow the pulse, lower blood pressure, and reduce the work of the heart.

Once your blood pressure is normal, your blood pressure should be measured regularly.

Blood pressure measurements may be performed weekly at first. Over time, they may be taken less frequently -- if blood pressure stays within normal range.

It's a good idea to measure your blood pressure at home. This will let you know how your blood pressure varies throughout the day.

You'll need to see your doctor for blood pressure checks, too. Blood tests may be needed with some treatments.

You'll need to stay on medications for a long time. After one year of normal blood pressure, your doctor may reduce your treatment. Medication treats hypertension, but generally does not cure it.

Don't stop your medication without first talking with your doctor.

Also, never run out of medicine. Keep a supply at home. Always refill your prescriptions before they run out.

Without medication, your blood pressure may rise suddenly and cause serious problems.

Resistant hypertension means blood pressure that stays high despite treatment with three different types of blood pressure medications. It's thought that about 30% of people with high blood pressure have resistant hypertension.

According to the American Heart Association, older age and obesity are two risk factors for resistant hypertension. Other studies suggest that people with resistant hypertension have associated risks factors such as diabetes, obstructive sleep apnea, enlargement of the heart chambers, and or chronic kidney disease.

In making a diagnosis, doctors have to decide if the person has true resistant hypertension or if they may not be taking their medications correctly or not adhering to treatment. These scenarios are not synonymous.

Sometimes, "white coat" hypertension is mistaken for resistant hypertension. With "white coat" hypertension, the patient may have a rise in blood pressure at the doctor's office but not at home.

The doctor may recommend 24-hour blood pressure monitoring to exclude "white coat" hypertension.

Patients with resistant hypertension often have many health problems. These conditions may include diabetes, sleep apnea, kidney disease, and atherosclerotic disease. These problems often make treatment difficult.

Along with using combination treatment, people with resistant hypertension may need treatment for secondary causes of hypertension, such as obstructive sleep apnea. Also, stopping drinking alcohol may help lower resistant hypertension.