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Guideline for the pharmacological treatment of hypertension in adults [Internet]. Geneva: World Health Organization; 2021.

Cover of Guideline for the pharmacological treatment of hypertension in adults

Guideline for the pharmacological treatment of hypertension in adults [Internet].

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6Implementation tools

6.1. Guideline recommendations

Graphic summaries of the guideline recommendations are presented below in an algorithmic approach (Figs 3 and 4). This maps the recommendations to a patient-care pathway.

Fig. 3. An approach for starting treatment with a single-pill combination.

Fig. 3

An approach for starting treatment with a single-pill combination.

Pharmacological treatment to be initiated under the following circumstances:

  • A diagnosis of HTN has already been made.
  • Initiation of pharmacological HTN treatment should start no later than four weeks after diagnosis of HTN.
  • If BP level is high or there is accompanying evidence of end organ damage, initiation of treatment should be started without delay.
  • Patient should be counselled about starting medication therapy.
  • Basic laboratory testing (electrolytes, creatinine, lipogram, glucose, HbA1C, urine dipstick, and ECG) to occur as long as it does not delay treatment.
  • A CV risk assessment can be conducted immediately (as long as it does not delay initiation of treatment) or at a later visit.
  • Consider using diuretics or CCB in patients 65 years or older, or those of African or Afro-Caribbean descent, beta-blockers (BBs) post MI, ACEis/ARBs in those with DM, heart failure or CKD.

Fig. 4. An approach for starting treatment not using a single-pill combination (i.e. with monotherapy or free combination therapy).

Fig. 4

An approach for starting treatment not using a single-pill combination (i.e. with monotherapy or free combination therapy).

Pharmacological treatment to be initiated under the following circumstances:

  • A diagnosis of HTN has already been made.
  • Initiation of pharmacological HTN treatment should start no later than four weeks after diagnosis of HTN.
  • If BP level is high or there is accompanying evidence of end organ damage, initiation of treatment should be started without delay.
  • Patient should be counselled about starting medication therapy.
  • Basic laboratory testing (electrolytes, creatinine, lipogram, glucose, HbA1C, urine dipstick, and ECG) to occur as long as it does not delay treatment.
  • A CV risk assessment can be conducted immediately (as long as it does not delay initiation of treatment) or at a later visit.
  • Consider using diuretics or CCB in patients 65 years or older, or those of African or Afro-Caribbean descent, beta-blockers (BBs) post MI, ACEis/ARBs in those with DM, heart failure or CKD.

6.2. Drug- and dose-specific protocols

Two examples of suggested drug and dose-specific protocols are presented below (Figs 5 and 6). These should be viewed as examples and other approaches are possible.

Algorithm 1: Initiation of treatment with a single-pill combination

  • Beginning treatment with two antihypertensive drugs from different classes is recommended when baseline BP is ≥20/10 mmHg above goal, and should be considered when baseline BP is ≥140/90 mmHg.
  • Drugs affecting the renin–angiotensin system (ACEis, ARBs, and aliskiren) have been associated with serious fetal toxicity, including renal and cardiac abnormalities and death; they are contraindicated for use during pregnancy.
Fig. 5. Algorithm 1.

Fig. 5

Algorithm 1. NOTE: Monitor potassium and kidney function when starting or changing the dose of ACEi/ARB or thiazide/thiazide-like diuretic, if testing is readily available and does not delay treatment. This protocol is contraindicated for women who are (more...)

Algorithm 2: Initiation of treatment not using a single-pill combination (i.e. with monotherapy or free combination therapy)

  • A CCB, rather than a thiazide-type diuretic or ACEi/ARB, was selected as first-line medication if one agent is used, to avoid the need for electrolyte measurements or to alleviate concerns regarding potential change in GFR.
  • Drugs affecting the renin-angiotensin system (ACEis, ARBs, and aliskiren) have been associated with serious fetal toxicity, including renal and cardiac abnormalities and death; they are contraindicated for use during pregnancy.
Fig. 6. Algorithm 2.

Fig. 6

Algorithm 2. NOTE: Monitor potassium and kidney function when starting or changing dose of ACEi/ARB or thiazide/thiazide-like diuretic, if testing is readily available and does not delay treatment. This protocol is contraindicated for women who are or (more...)

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