Clinical Strategies For Managing Resistant Hypertension: Emerging Tools and Therapeutic Insights - Episode 10
Scenarios to Discontinue Antihypertensive Medications
Panelists discuss how medication reduction is occasionally possible in well-controlled patients over time, particularly with diuretics when sodium intake decreases or calcium channel blockers to reduce edema, while being cautious about maintaining adequate blood pressure control and avoiding drugs that worsen kidney function.
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While antihypertensive therapy typically involves progressive medication addition, certain clinical scenarios allow for careful medication reduction. Long-term well-controlled blood pressure can lead to vascular remodeling and decreased treatment requirements over time. Successful de-escalation most commonly involves diuretic reduction when patients achieve significant dietary sodium restriction, evidenced by BUN-to-creatinine ratios exceeding 20:1 without edema.
GLP-1 receptor agonists causing substantial weight loss create opportunities for both diabetes and hypertension medication reduction. Clinicians should monitor for symptomatic hypotension as patients lose weight and may need to reduce antihypertensive dosing proactively. This represents a paradigm shift toward addressing root causes of hypertension rather than simply adding medications, particularly relevant given the obesity epidemic’s role in resistant hypertension.
When de-escalation becomes necessary, calcium channel blockers represent the preferred choice for reduction due to fewer pleiotropic benefits compared with ACE inhibitors or ARBs. The renin-angiotensin system provides cardiovascular and renal protection beyond blood pressure lowering, including anti-fibrotic and anti-inflammatory effects. However, dihydropyridine calcium channel blockers should never be used without concurrent ACE inhibitor or ARB therapy due to potential adverse renal effects from increased intraglomerular pressure.
