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What Are the Best BP Drugs for Hypertension?

If you have hypertension why did your doctor choose one med over another? You might be surprised to learn which BP drugs score highest.
What Are the Best BP Drugs for Hypertension?
Man check blood pressure. Self care heart rate monitoring with digital pressure gauge.

The American Heart Association states that over 100 million Americans have high blood pressure (BP). It is defined as at or above 130/80. That means roughly 1 out of every 2 adults in the United States has hypertension. If it can’t be controlled by diet, weight loss or exercise, chances are good the doctor will prescribe medication. But which BP drugs are best to control high blood pressure?

A Dirty Little Secret:

Millions of people shop for cars, appliances, mattresses, lawn mowers and other consumer items by checking objective resources such as Consumer Reports (CR). This allows people to make informed decisions based on things like effectiveness, reliability, ease of use, cost and safety. There is no such evaluative process when it comes to medications.

Drug companies are not anxious to have their products tested against competing brands. Such comparisons might give health professionals objective information about the safest and most effective medicines to prescribe. Advertising is far easier to control. That may be why you see so many prescription drug commercials on television.

How Do Doctor’s Decide on the Best BP Drugs to Prescribe?

Doctors have long assumed that all BP drugs are similarly effective in protecting people from heart attacks, strokes and heart failure. If two different kinds of medications get blood pressure at or below 130/80 many doctors may conclude that they are comparable. But are all BP drugs created equal?

Comparison of BP Drugs: Effectiveness and Safety

A study published in The Lancet (Nov. 16, 2019) examined data from 4.9 million patients in real-world situations. They introduced their research by pointing out the problem:

“Patients and physicians have a wide range of pharmacological options to treat hypertension but little guidance on which specific first-line agent to initiate.

“Accordingly, we developed the open-science, large-scale evidence generation and evaluation across a network of databases for hypertension (LEGEND-HTN) study to compare common antihypertensive drug treatments by a systematic, large-scale analysis across nine observational databases from the Observational Health Data Science and Informatics (OHDSI) distributed data network. This novel approach used massive data across several countries and synthesised tens of thousands of comparisons with analytic techniques to minimise residual confounding.”

Comparison of BP Drugs for Safety and Effectiveness:

The researchers discovered that old-fashioned diuretics such as hydrochlorothiazide were more effective than many popular blood pressure medications. For initial treatment, the diuretics outperformed ACE inhibitors like lisinopril, calcium channel blockers such as amlodipine and angiotensin receptor blockers like losartan or valsartan.

There were fewer heart attacks, strokes and hospitalizations for heart failure when hypertensive patients began treatment with thiazide or thiazide-like diuretics. These patients also experienced fewer side effects such as digestive distress or kidney problems. Calcium channel blockers (also known as calcium antagonists) were less effective than all of the other classes of blood pressure medications.

This comprehensive study suggested that if doctors had started treatment with thiazide-type BP drugs instead of ACE inhibitors like lisinopril:

“…more than 3100 major cardiovascular events could potentially have been avoided. This number equates to 1.3 cardiovascular events avoided for every 1000 patients who initiate with a thiazide or thiazide-like diuretic instead of an angiotensin-converting enzyme inhibitor, yielding a substantial public health impact, particularly given the more favourable safety profile of thiazide or thiazide-like diuretics.”

What BP Drugs Are Prescribed Most Often?

The latest data we have suggests that most prescribers have either not seen The Lancet study or have ignored its findings. That because the numbers demonstrate that thiazide or thiazide-like diuretics are not at the top of the list:

BP Drug Prescriptions:

  • Lisinopril (an ACE inhibitor) tops the list at 20 million patients and 105 million prescriptions dispensed
  • Amlodipine (a calcium channel blocker) has 15 million patients and 73 million prescriptions dispensed
  • Metoprolol (a beta blocker) has 13 million patients and 68 million prescrptions dispensed
  • Losartan (an angiotensin receptor blocker or ARB) has 10 million patients and 52 million prescriptions dispensed
  • Hydrochlorothiazide (a thiazide diuretic) comes in last with 9 million patients and 42 million prescriptions dispensed

Judging from dispensing records, thiazide diuretics do not come close to winning the BP Drugs Sweepstakes. Calcium channel blockers like diltiazem and verapamil “underperformed all other drug classes.” ACE inhibitors, which did win the BP Drugs Sweepstakes had higher rates of side effects than thiazides.

No Second Guessing:

We are not trying to second-guess your prescriber. There may be excellent reasons why your doctor or nurse practitioner did not start you on a thiazide diuretic to lower blood pressure. But you might want to show them this article and see why they chose the BP drugs they did prescribe.


Thiazide Diuretics Not Without Risks:

The authors of this research note that thiazide BP drugs can deplete the body of both potassium (hypokalemia) and sodium (hyponatremia). We have also written about other side effects associated with these diuretics at these links:

Hydrochlorothiazide (HCTZ) Side Effects, Complications and Gout!
New blood pressure guidelines will likely translate to millions more taking diuretics. Do people know about hydrochlorothiazide (HCTZ) side effects?


Hydrochlorothiazide Side Effects: Skin Cancer and More!
Few health professionals think hydrochlorothiazide side effects are serious. But a Danish study links HCTZ with squamous cell skin cancer.

If you would like to learn more about the benefits and risks of most BP drugs as well as learn about nondrug options, here is a link to our eGuide to Blood Pressure Treatment. You can find it in the Health eGuide section of this website.

Reader Comments?

What has been your experience with BP drugs? Has one worked really well to control hypertension without side effects? Have you had trouble with ACE inhibitors such as lisinopril? Please share your story in the comment section below. Do you know someone who might benefit from this article? Please send it their way by using the email icon at the top of this page. 

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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  • Suchard, M.A., et al, "Comprehensive comparative effectiveness and safety of first-line antihypertensive drug classes," Lancet, Oct. 24, 2019, doi: 10.1016/S0140-6736(19)32317-7
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