Hesperian Health Guides
Heart Disease and High Blood Pressure: Medicines
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Types of blood pressure medicines
Medicines for high blood pressure work a little differently in each person and each person’s heart problem can be different. When health workers treat high blood pressure and other heart problems with medicines, they usually start with a low dose. Depending on how well it works for that person and whether blood pressure goes down enough, the medicine is adjusted to make the dose a little more or a little less. Another medicine might be added to the first, or used instead of the first. When blood pressure readings are at normal levels, that means you are taking the right dose and type of medicine or medicines for your condition and this is called having your blood pressure controlled or under control. When starting tretament, get blood pressure checked every few weeks.
Health workers also monitor the side effects, if any, the medicine causes, and know if the medicine can be easily found and if it is affordable or free. If the person stops taking the medicine because of side effects or the cost, the health worker can work to find a solution.
Common medicines to treat adult high blood pressure include:
- Hydrochlorothiazide (HCTZ) or another diuretic (“water pills”)
- Amlodipine or another calcium channel blocker (the names of these often end with -dipine)
- Captopril, enalapril or another ACE inhibitor (the names of these often end in -pril)
- Losarten or another ARB (the names of these often end in -sarten)
- Atenolol or another beta blocker (the names of these often end in -lol). When beta blockers are used to treat high blood pressure, they are used in combination with other medicines.
There are also medicines that combine 2 heart medicines in 1 tablet. These may be more expensive than buying each separately, but may be more convenient.
Learn from experienced health workers which medicines can be combined. Learn the best starting dose for each medicine when the person has another condition along with high blood pressure, such as congestive heart failure, high cholesterol, diabetes, or kidney problems.
For a person over 60 taking high blood pressure medicines for the first time, start with the lowest dose.
If medicines do not seem to be working, look for kidney disease, problems taking the right dose, what other medicines or drugs they take, or thyroid problems.
Diuretics (“water pills”)
Hydrochlorothiazide (HCTZ), chlorthalidone, spironolactone, bendroflumethazide, triamterene, and furosemide are diuretics.
Diuretic medicines help the kidneys get rid of extra fluid and sodium by causing the person to urinate more often. With less fluid in the body, blood pressure goes down. Some diuretics also make the blood vessels become wider to reduce blood pressure.
Diuretics are sometimes used to treat the swelling (edema) from congestive heart failure if the health worker can monitor with lab tests how it is affecting the body.
Dizziness, frequent urination, headache, feeling thirsty, muscle cramps, and upset stomach. Most people take diuretics in the morning to avoid urinating frequently at night.
Pregnant women should not use diuretics unless other medicines do not control their blood pressure.
Danger signs: severe rash, problems breathing, problems swallowing, and intense joint pain, especially in the feet. Get help right away.
Diuretics such as HCTZ, chlorthalidone, and furosemide take potassium out of the body. Eat plantains, bananas, oranges, lemon or avocado often to replace the potassium. If a blood test shows that potassium levels are low, some people will need potassium pills. Spironolactone and triamterene keep the potassium in the body. They are sometimes used in combination with the other diuretics to keep the potassium level normal but need more caution if used together with ACE inhibitors or ARBs.
Diuretics also take magnesium out of the body. Eat greens, yogurt, and squash seeds to replace magnesium.
Potassium levels and kidney function should be checked with lab tests a few weeks after starting diuretics and then every 6 to 12 months if you are taking hydroclorothiazide, and even more often if you are taking furosemide. Furosemide is a stronger diuretic and the person needs to be monitored closely.
HYDROCHLOROTHIAZIDE (HCTZ)
Hydrochlorothiazide comes in 25 mg and 50 mg tablets.
For high blood pressure
If necessary, the dose can be increased to 25 mg each day after a few weeks if the blood pressure is not controlled with the lower dose.
Do not take more than 25 mg in one day. Taking more does not lower your blood pressure, it only increases side effects.
Calcium channel blockers
Amlodipine, nifedipine, diltiazem, and verapamil are calcium channel blockers.
Calcium channel blockers prevent calcium from entering the blood vessels and the heart. This relaxes the blood vessels, helping lower blood pressure.
They are also used for chest pain (angina).
People with diabetes can take calcium channel blockers.
Amlodipine and nifedipine can cause ankle swelling. Prevent swelling by avoiding salty foods, exercising, and keeping legs elevated when sitting. If swelling continues, you may have to change medicine.
Minor side effects such as a mild headache, feeling drowsy, or upset stomach sometimes go away a week or two after the starting the medicine. Talk to your health worker about changing the medicine if side effects continue.
Not all calcium channel blockers can be used during pregnancy.
People with some types of congestive heart failure and some other heart conditions should not use calcium channel blockers.
People taking calcium channel blockers while also taking statins will need a lower dose of statins.
Danger signs: severe rash, chest pain, fainting, irregular heartbeat, swelling of any part of the face, mouth, arms, or legs. Get help right away.
Amlodipine comes in 5 mg and 10 mg tablets.
For high blood pressure
After a few weeks, measure to see if blood pressure is controlled. If necessary, the dose can be increased to 10 mg.
Do not take more than 10 mg in one day.
ACE inhibitors and ARBs
Angiotensin-Converting Enzyme (ACE) inhibitors and Angiotensin Receptor Blockers (ARBs) are two types of medicines that act in similar ways. Both types are used for lowering high blood pressure, for congestive heart failure, for other kinds of heart disease, and to help protect the kidneys of people with diabetes.
ACE inhibitors and ARBs block the substance in the blood that makes the blood vessels tighten and narrow. When the blood vessels relax and widen, blood pressure goes down.
Captopril, enalapril, lisinopril are ACE inhibitors. Losartan is an ARB.
ACE inhibitors can cause a dry cough. If you get a dry cough, switch to an ARB, such as losartan, which does not cause coughing.
Other possible side effects: rash, dizziness, feeling tired, headache, problems sleeping, or fast heartbeat.
Do not give to pregnant women or to women who may become pregnant. ACE inhibitors and ARBs are dangerous for a developing baby.
Avoid use in people with severe kidney disease.
Avoid ibuprofen and other anti-inflammatory medicines when taking ACE inhibitors or ARBs.
Danger signs: chest pain, problems breathing, problems swallowing, swelling of any part of the face, mouth, or legs. Get help right away.
ACE inhibitors and ARBs increase potassium. A blood test should be done a few weeks after starting an ACE inhibitor to monitor the health of the kidneys and the level of potassium. This is especially important if the person has even mild kidney disease. Use extreme caution and monitor the potassium levels through blood tests carefully if the person is also taking one of these diuretics: spironolactone or triamterene.
CAPTOPRIL
Captopril comes in 25 mg and 50 mg tablets
For high blood pressure
After a few weeks, measure to see if blood pressure is controlled. If necessary, the dose can be increased. The next dose to try is 50 mg each day, divided in half and taken 2 times a day (25 mg each time). If necessary, this can be increased to a dose of 100 mg each day, divided in half and taken 2 times a day (50 mg each time).
If captopril is used with diuretics or the person is age 60 or older, then the starting dose is 12.5 mg each day, divided in half, and given 2 times a day (6.25 mg each time).
Do not take more than 100 mg total in one day.
ENALAPRIL
Enalapril comes in 2.5 mg, 5 mg, 10 mg and 20 mg tablets
For high blood pressure
After a few weeks, measure to see if blood pressure is controlled. If necessary, the dose can be increased. Most people do well with a dose between 10 mg to 20 mg each day. When the dose is 10 mg or more, it works better if the dose is divided in half and given 2 times a day.
If enalapril is used with diruretics, the person is age 60 or older, or has mild kidney disease, start with 2.5 mg per day.
Do not take more than 40 mg in one day.
LOSARTAN
Losartan comes in 25 mg, 50 mg, and 100 mg tablets.
For high blood pressure
After a few weeks, measure to see if blood pressure is controlled. If necessary, the dose can be increased to 100 mg each day, either 1 time each day, or divided in half and taken 2 times a day (50 mg each time).
If losartan is used with diuretics, then the starting dose is a total of 25 mg taken 1 time each day.
Do not take more than 100 mg in one day.
Beta blockers
Beta blockers slow the heartbeat so the heart pumps with less force, resulting in lower blood pressure. If taken every day, beta blockers help lower high blood pressure and can help with chest pain (angina). Beta blockers are usually used together with diuretics or other medicines when taken to lower blood pressure. Some beta blockers are used to treat congestive heart failure.
Atenolol, metoprolol, bisoprolol, and carvedilol are beta blockers.
Feeling tired, upset stomach, headache, dizziness, constipation, diarrhea, feeling lightheaded.
If these are mild, they will sometimes go away after a few weeks of using the medicine.
Not all beta blocker medicines may be used during pregnancy.
People with diabetes should use beta blockers with caution if they are having episodes of low blood sugar.
Beta blockers can make asthma worse, so people with asthma should use with caution.
Beta blockers can also lower the pulse. Reduce the dose if the pulse is less than 60 beats per minute.
Danger signs: chest pain, problems breathing, slow heartbeat, swelling in the hands, feet, or legs.
These medicines should be started at a low dose and gradually increased every 1 or 2 weeks. If you are taking a high dose of these medicines and need to stop them, they should be slowly decreased over a few weeks.
ATENOLOL
Atenolol comes in 25 mg and 50 mg tablets
For high blood pressure
After a few weeks, measure to see if blood pressure is controlled. If necessary, the dose can be increased by adding 25 mg more for a total of 50 mg each day. Measure the blood pressure again and repeat the increase if necessary after 2 more weeks (to 75 mg, 1 time each day), and again in 4 weeks (100 mg ,1 time each day).
Do not take more than 100 mg in one day.
METOPROLOL TARTRATE
Metoprolol tartrate is a short-acting medicine that is taken 2 times a day. It is a different medicine than metoprolol succinate which is long-acting.
Metoprolol tartrate usually comes in 50 mg and 100 mg tablets
For high blood pressure
After a few weeks, measure to see if blood pressure is controlled. If necessary, the dose can be increased by adding 50 mg to the amount per day. Measure the blood pressure again and repeat the increase if necessary after 2 more weeks. The usual dose is 200 mg to 400 mg each day, divided in half and taken 2 times each day (100 mg to 200 mg each time).
Do not take more than 400 mg in one day.
Statins
Simvastatin, lovastatin, atorvastatin, and pravastatin are statins.
Statins make a person’s liver produce less cholesterol. Too much cholesterol limits blood circulation and makes it harder for the heart to pump.
Statins are used to prevent heart attacks and strokes in persons who have already had one. They are also used to prevent heart emergencies in people with diabetes or other health problems that make a heart attack or stroke more likely.
Statins are very helpful for people who have these severe problems. They are also given to people to lower unhealthy levels of cholesterol.
There are moderate intensity statins (such as simvastatin) and stronger high intensity statins (such as atorvastatin) used for people with higher risk of a heart attack.
Statin medicines can cause muscle pain. When this is mild and not all over the body, the dose can be lowered to limit the discomfort. But if the muscle pain is severe or is felt all over the body (like having the flu), stop taking the statin and see a health worker.
Minor side effects such as a headache, upset stomach or constipation are common and often go away after the body becomes used to the medicine.
Statins should not be used during pregnancy and are not usually given to women who could become pregnant.
Some statin medicines should not be mixed with other medicines. Sometimes combining medicines changes the dose of one or both. For example, people taking amlodipine, cannot take more than 20 mg of simvastatin. Be sure to tell your health worker about all the medicines you are taking so she can check for drug interactions.
Danger signs: severe muscle aches or muscle aches that affect the whole body. Stop taking the statin medicine and see a health worker.
Statins are usually started at a moderate dose and decreased if there are side effects. This is different than some high blood pressure medicines where a lower dose is tried first and then slowly raised.
Statins work best if taken before going to sleep.
SIMVASTATIN
Simvastatin comes in 5 mg, 10 mg, 20 mg and 40 mg tablets.
To lower cholesterol for people at high risk of heart attacks
Most people will have a dose of 10 mg to 40 mg. When combined with certain medicines, the amount of simvastatin will be lower. It is important to know about all the medicines a person is taking before starting simvastatin.
Do not take more than 40 mg in one day.