FAMILY MEDICINE® COLUMN

By Martha A. Simpson, D.O., M.B.A.
Associate Professor of Family Medicine
Ohio University College of Osteopathic Medicine

DOCTOR’S HIGH BLOOD PRESSURE RX DEPENDS ON RISK FACTORS

Question: Is there a method doctors use to determine the best blood pressure medicine to give their patients? It seems to me they only use a trial and error method to decide what medicine to give for blood pressure problems.

Answer: The simple answer to your question is “yes.” Doctors do have a protocol to use in trying to determine the best medication to use once a person has been diagnosed with high blood pressure (HBP). However, sometimes, as you indicate, there’s a certain level of “trial and error” involved, too.
About 90 percent of all cases of high blood pressure fall in a category we call “essential hypertension.” This is actually just a fancy phrase that means we don’t really know the cause of the HBP. In the other 10 percent of the cases, there’s usually an underlying medical problem like a kidney disorder or atherosclerosis. Here treatment aimed at the specific medical problem will sometimes make the high blood pressure go away.
I’ll direct the rest of my column today toward cases of essential hypertension. Once this diagnosis has been made, the first thing your physician will do is size up your cardiovascular risk level.
Let me give you an example. You’d be at low risk if you don’t smoke, don’t have diabetes, have normal cholesterol and triglycerides, have good kidney function, are under 60, and a female. In addition, you’d get positive points in the risk assessment if you have no family history of cardiovascular disease and have no evidence of current cardiovascular disease. If you fit this profile, and your blood pressure was only moderately elevated (150/95), you might be asked to make lifestyle changes like increasing exercise and losing weight. If the blood pressure didn’t come down in a few months, then the doctor would most likely start you on a diuretic, or water pill.
On the other hand, your physician might assess you as having a moderate risk if three or more of the following apply: you smoke, have diabetes, are over 60, are a male, or a post-menopausal woman. In this case, lifestyle changes and medication would be started at the same time. If there was little or no response to the medication and lifestyle changes in a few months, then a second medication might be added.
If you have a high cardiovascular risk, the blood pressure management is more aggressive. Your doctor might recommend three or more different drug agents, plus lifestyle changes.
Trained physicians can assess HBP risks very quickly and in their heads. Usually this works quite well. I must admit, though, that there are times when our educated guesses are wrong, and we must try several medications before we find the right one that works for a particular patient. Perhaps this was your situation.
Complicating things a bit is the use of formularies by insurance companies and Medicare. This may limit your physician’s choice and forces the use of older, cheaper medications or ones he or she is not familiar with. Usually the formularies are broad enough that the right drug can be chosen.
Going to your regular family doctor rather than a hospital emergency department or urgent care center improves your odds of getting things right the first time. This is because your physician already knows you and your history.

Family Medicine® is a weekly column. To submit questions, write to Martha A. Simpson, D.O., M.B.A., Ohio University College of Osteopathic Medicine, P.O. Box 110, Athens, Ohio 45701, or via e-mail to readerquestions@familymedicinenews.org. Medical information in this column is provided as an educational service only. It does not replace the judgment of your personal physician, who should be relied on to diagnose and recommend treatment for any medical conditions. Past columns are available online at www.familymedicinenews.org.