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When should drugs for high blood pressure be initiated?

Q: I am 52 years old. At an interval of 15-20 days I used to get strokes causing indigestion, sweating, vomiting sensation, etc. During an annual check-up last year, my blood pressure was found between 160-100. Normally it ranges between 140-90. A regular record of alternate day indicated 170-105 on one day. One of the doctors advised salt control, occasional NiteRest and some pranayam, while another doctor suggested taking Stamlo beta - OD. Till date I have not started this. After going through a reply on your site, I am now confused whether or not to start the drug due to its dual combination? I am also suffering from rheumatoid arthritis and gout for the last 2 years.

A:There are globally accepted guidelines on the diagnosis and treatment of high blood pressure. A minimum of 3 blood pressure readings should be done per visit on up to 4 different days (7-10 days apart). If diastolic blood pressure is consistently more than 100 (not just once or twice), then non-drug measures should be undertaken such as reduce weight if necessary (you are over-weight at 74 kg with a height of 164 cm and need to loose at least 5-6 kg), stop smoking, undertake mild exercise (such as brisk walk for 45 minutes daily to cover no less than 4.5 km), salt restriction, moderation in alcohol consumption and Yoga, if possible. If the above measures fail to bring down the pressure, then drug therapy can be instituted. The global guidelines for patients of high blood pressure below 55 years of age are as follows:

  • In patients aged below 55 years of age, first choice of initial therapy should be an ACE inhibitor such as enalapril (sold as BQL in India). If an ACE inhibitor is not tolerated (some patients may get irritating cough), an Angiotensin receptor blocker such as losartan (sold as Losacar in India) can be used. If two drugs are required then add either a calcium channel blocker (such as amlodipine sold under the trade name of Amlodac 5 mg) or a diuretic such as metolazone (sold under the trade name of Metoz) 2.5 mg daily in the morning. However diuretics should be avoided in patients of gout.
  • For all patients (whether below or above 55 years of age) if treatment with three drugs is required, the combination of ACE inhibitor such as BQL or an Angiotensin receptor blocker such as Losacar (if an ACE inhibitor is not tolerated due to cough), a calcium channel blocker such as Amlodac and a diuretic such as Metoz should be used (with caution in patients of gout).
  • Beta-blockers (such as atenolol, one of the ingredients of Stamlo Beta) are not recommended because they perform less well than other drugs, and the increasing evidence that they carry an unacceptable risk of provoking diabetes. Besides, atenolol can lead to impotence in sexually active males. Stamlo Beta is a fixed-dose combination of atenolol and amlodipine. Fixed-Dose Combinations (FDCs): Medicines are discovered individually and are supposed to be taken separately. A huge number of irrational, illegal combinations of drugs are being sold in India; quite a few without mandatory approval of the Drugs Controller General, India (DCGI). Except in a few cases (such as TB medicines), it is always better to take medicines separately so that dosage can be adjusted and side effects monitored.


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