Emerging Treatment Options in Patients With Difficult-to-Treat Hypertension - Episode 12
Challenges in Managing Resistant Hypertension
A panelist discusses how spironolactone is typically the first fourth medication added for resistant hypertension but has limitations in patients with kidney disease or electrolyte issues, necessitating alternative strategies like renal denervation and highlighting the need for multiple treatment approaches to avoid polypharmacy-related adherence problems.
Advanced Pharmacological Management and Adherence
The typical next step after optimizing a three-drug regimen is adding a mineralocorticoid receptor antagonist like spironolactone, which is generally well-tolerated and effective but unsuitable for patients with electrolyte disturbances or azotemia. Patient reluctance to take spironolactone due to information from media, online sources, or pharmacists creates the need for alternative therapies. For patients with chronic kidney disease, options become more limited as many interventions including mineralocorticoid receptor antagonists and renal denervation (which requires GFR above 40) may be inappropriate. Additionally, polypharmacy creates adherence challenges, necessitating a wide variety of treatment strategies beyond mineralocorticoid receptor antagonists.
Medication adherence is critical, as many apparently resistant patients respond well when consistently taking prescribed medications. Effective strategies for improving adherence include explaining the purpose of blood pressure control in terms of reducing stroke and cardiovascular event risk, with even modest blood pressure reductions significantly decreasing these risks. Prescribing the right medications is equally important, using fixed-dose combinations with once-daily formulations whenever possible. Fixed-dose combinations containing two or even three drugs in a single pill can significantly improve adherence by reducing pill burden.
