NICE: draft updated hypertension guidelines

  • National Institute for Health and Care Excellence

  • curated by Dawn O'Shea
  • UK Medical News
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Updated draft guidelines from NICE recommend offering antihypertensive medication to people aged

Key treatment recommendations in the draft guidance include:

Step 1

  • Angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) for adults with type 2 diabetes (T2D) or aged
  • Calcium-channel blocker (CCB) for adults aged ≥55 years or those of African/Caribbean origin without T2D.
  • Do not combine ACE-I with ARB.
  • If CCB is not tolerated, offer thiazide-like diuretic.
  • If there is evidence of heart failure, offer a thiazide-like diuretic and follow NICE guideline on chronic heart failure.
  • If starting or changing diuretic, thiazide‑like diuretic is preferred to conventional thiazide diuretic.

Step 2

  • If uncontrolled on step 1 ACE-I or ARB, offer a CCB or thiazide-like diuretic.
  • If uncontrolled on step 1 CCB, offer ACE-I, ARB or thiazide-like diuretic.
  • If uncontrolled in adults of African and Caribbean origin without T2D taking step 1, consider adding ARB in preference to ACE-I.

Step 3 

  • If hypertension is not controlled with step 2 treatment, offer a combination of ACE-I or ARB, and CCB and thiazide-like diuretic.

Step 4 

  • For confirmed resistant hypertension, consider adding a fourth antihypertensive drug or seeking expert advice.
  • Add low-dose spironolactone for adults with blood potassium level of ≤4.5 mmol/L.
  • Use caution in people with reduced estimated glomerular filtration rate.
  • Monitor blood sodium and potassium and renal function within 1 month of starting additional diuretic treatment and repeat as needed.
  • Consider alpha-blocker or beta-blocker for adults with a blood potassium level >4.5 mmol/l.
  • If blood pressure remains uncontrolled with the optimal tolerated doses of 4 drugs, seek expert advice.

The draft guidelines are open for consultation until 23 April 2019.