Stage 2 HTN or stage 1 with end-organ damage / CVD / DM.
Regimens
Step 1 <55 / DM / CKD
ACEi (ramipril 2.5 mg OD, titrate to 10 mg) or ARB
Step 1 ≥55 / Black African–Caribbean
CCB (amlodipine 5 mg OD, max 10 mg)
Step 2
Add the other class (ACEi + CCB)
Step 3
Add thiazide-like diuretic (indapamide 2.5 mg OD)
Step 4 (resistant)
Spironolactone 25 mg OD if K⁺ ≤4.5; else α/β-blocker
Monitoring
- • Home BP target <135/85 (<145/85 if ≥80 y)
- • U&E within 2 weeks of ACEi
- • Postural BP, K⁺ for spironolactone
Common prescribing errors
- ⚠ ACEi + ARB combination
- ⚠ ACEi in pregnancy / bilateral RAS
- ⚠ Not measuring postural BP in elderly
