Hypertension in Adults
Introduction
Hypertension is a persistent elevation in blood pressure that increases cardiovascular, cerebrovascular, and kidney risk. Current Canadian guidance defines hypertension in adults as blood pressure at or above 130/80 mm Hg when measured using recommended methods.[1]
Symptoms
Most patients have no reliable symptoms, so diagnosis depends on accurate measurement rather than how the patient feels. Markedly elevated readings with acute neurologic, cardiac, respiratory, or visual symptoms require urgent medical assessment.[2]
Goals
Reduce preventable cardiovascular and kidney events while avoiding treatment-related harm. A systolic blood pressure below 130 mm Hg is the usual treatment target when it is tolerated; individualize when frailty, orthostasis, or limited life expectancy changes the balance.[1]
Risk Factors
- Older age, family history, tobacco exposure, excess sodium, low physical activity, and excess alcohol.
- Diabetes, chronic kidney disease, dyslipidemia, obesity, established cardiovascular disease, and sleep apnea.
- Medicines and substances that can raise blood pressure, including NSAIDs, stimulants, decongestants, systemic corticosteroids, and excess licorice.
Assessment
Confirm technique, cuff size, repeated readings, and the possibility of white-coat or masked hypertension. Use validated automated office measurement and confirm with out-of-office measurement when feasible.[3]
- Review adherence, current medicines, pregnancy possibility, alcohol, sodium, and symptoms of secondary causes.
- Assess global cardiovascular risk and target-organ effects; obtain patient-specific laboratory testing according to the clinical context.
Non-Pharmacologics
- Use a dietary pattern rich in vegetables, fruit, whole grains, and minimally processed foods; reduce sodium.
- Build regular aerobic and resistance activity within the patient's capacity.
- Support weight management, tobacco cessation, moderation of alcohol, and adequate sleep.
Lifestyle measures are recommended for all patients and continue after drug therapy starts.[1]
Pregnancy and breast feeding
Pregnancy and breast feeding require a separate benefit-risk review because usual adult targets and drug choices do not automatically apply. Confirm pregnancy status when relevant and obtain pregnancy-specific prescriber guidance before initiating, continuing, or changing therapy.[2]
Monitoring
- Reassess blood pressure, adherence, orthostatic symptoms, and adverse effects after initiation or dose changes.
- Monitor renal function and electrolytes when the selected drug or patient factors warrant it.
- Once stable, continue periodic office or home readings and revisit cardiovascular risk.
Tips
- Ask the patient to bring the home monitor and readings; confirm technique.
- Simplify the regimen and use single-pill combinations when clinically appropriate.
- Before labeling resistant hypertension, check measurement, adherence, substances that raise blood pressure, and secondary causes.
Decision Making Logic
- Validate the measurement and identify any hypertensive emergency features.
- Confirm persistent hypertension with repeat or out-of-office readings.
- Assess cardiovascular risk, target-organ effects, comorbidities, pregnancy, and contributors.
- Start lifestyle treatment for everyone; add pharmacotherapy according to pressure and risk.
- Select a class using comorbidities, contraindications, interactions, laboratory values, cost, and patient preference.
- Titrate, combine complementary classes when needed, and monitor until the individualized target is reached.
Drug Tables
How to use these tables: Doses are adult oral hypertension doses and require patient-specific confirmation. Select any drug name to open its complete Pharmasist Drug Database page.
Current Canadian guidance favours initial low-dose combination treatment using two complementary first-line classes: an ACE inhibitor or ARB, a thiazide or thiazide-like diuretic, and/or a long-acting dihydropyridine calcium-channel blocker. If two drugs do not achieve target, use all three classes; do not combine an ACE inhibitor with an ARB. Spironolactone is the preferred next consideration for confirmed resistant hypertension when potassium and kidney function allow.[2][4][5][6][7]
Alpha1-adrenergic antagonists
Not initial hypertension therapy. Orthostatic hypotension, headache, drowsiness, palpitations and nasal congestion are common class concerns. First-dose or rapid-titration syncope can occur; start low, titrate slowly and restart at the initial dose after a multi-day interruption. Additive hypotension may occur with other blood-pressure-lowering drugs.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Doxazosin generics | Reserve for a specific indication or add-on treatment. | Initial 1 mg once daily; usual 1-8 mg/day; maximum 16 mg/day. | Orthostasis, dizziness, headache, drowsiness, palpitations, nasal congestion. | Other antihypertensives increase first-dose hypotension and syncope risk. |
| Prazosin generics | Reserve for a specific indication or add-on treatment; give the first dose with the evening meal. | Day 1: 0.5 mg with evening meal; then 0.5 mg BID-TID for 3 days and increase gradually; maximum 20 mg/day. | Orthostasis, dizziness, headache, drowsiness, palpitations, nasal congestion. | Other antihypertensives increase first-dose hypotension and syncope risk. |
| Terazosin generics | Reserve for a specific indication or add-on treatment. | Initial 1 mg at bedtime; usual 1-5 mg/day; maximum 20 mg/day, once daily or divided BID. | Orthostasis, dizziness, headache, drowsiness, palpitations, nasal congestion. | Other antihypertensives add hypotension; verapamil can increase terazosin concentrations. |
Angiotensin-converting enzyme inhibitors
Avoid in pregnancy and counsel people who could become pregnant. Dry cough, hyperkalemia and uncommon angioedema are class effects. Renal failure can occur with bilateral renovascular disease, volume depletion or concurrent NSAID use. Potassium supplements and potassium-sparing drugs increase potassium; NSAIDs can blunt effect and increase renal risk; lithium concentrations may rise. Consider a 50% lower start in diuretic-treated or hypovolemic patients and reassess serum creatinine and potassium after initiation and titration.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Benazepril generics | ACE inhibitor option; avoid in pregnancy and previous ACE-inhibitor angioedema. | Initial 10 mg/day; usual 20 mg/day; maximum 40 mg/day, once daily or divided BID. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Captopril generics | Shorter-acting ACE inhibitor requiring divided administration. | Initial 25 mg/day; usual 75 mg/day; maximum 150 mg/day divided BID-TID. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Cilazapril Inhibace, generics | ACE inhibitor option. | Initial 2.5 mg/day; usual 2.5-5 mg/day; maximum 10 mg/day, once daily or divided BID. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Enalapril Vasotec, generics | ACE inhibitor option. | Initial 5 mg/day; usual 10-40 mg/day; maximum 40 mg/day, once daily or divided BID. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Fosinopril generics | ACE inhibitor option. | Initial 10 mg/day; usual 20 mg/day; maximum 40 mg/day, once daily or divided BID. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Lisinopril Zestril, generics | Once-daily ACE inhibitor option. | Initial 10 mg/day; usual 20 mg/day; maximum 40 mg once daily. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Perindopril erbumine Coversyl, generics | ACE inhibitor option. | Initial 4 mg/day; maximum 8 mg/day, once daily or divided BID. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Quinapril generics | ACE inhibitor option. | Initial 10 mg/day; maximum 40 mg/day, once daily or divided BID. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Ramipril Altace, generics | ACE inhibitor option. | Initial 2.5 mg/day; usual 10 mg/day; maximum 20 mg/day, once daily or divided BID. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Trandolapril Mavik, generics | Once-daily ACE inhibitor option. | Initial 1 mg/day; maximum 4 mg once daily. | Cough, hyperkalemia, hypotension, renal dysfunction; rare angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
Angiotensin II receptor blockers
Avoid in pregnancy and counsel people who could become pregnant. Hyperkalemia and renal dysfunction can occur, particularly with bilateral renovascular disease, hypovolemia or NSAID exposure; angioedema has been reported. Potassium-retaining drugs raise potassium, NSAIDs reduce antihypertensive effect and increase renal risk, and lithium concentrations may increase. Start lower when volume depleted and recheck serum creatinine and potassium.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Azilsartan medoxomil Edarbi, generics | Once-daily ARB; do not combine routinely with an ACE inhibitor. | Initial 40 mg/day; maximum 80 mg once daily. | Hyperkalemia, hypotension, renal dysfunction; reported angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Candesartan cilexetil Atacand, generics | Once-daily ARB; do not combine routinely with an ACE inhibitor. | Initial 8 mg/day; usual 8-16 mg once daily. | Hyperkalemia, hypotension, renal dysfunction; reported angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Irbesartan Avapro, generics | Once-daily ARB; do not combine routinely with an ACE inhibitor. | Initial 150 mg/day; usual 150-300 mg once daily. | Hyperkalemia, hypotension, renal dysfunction; reported angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Losartan Cozaar, generics | ARB option; do not combine routinely with an ACE inhibitor. | Initial 50 mg/day; usual 25-100 mg/day; maximum 100 mg/day, once daily or divided BID. | Hyperkalemia, hypotension, renal dysfunction; reported angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Olmesartan medoxomil Olmetec, generics | Once-daily ARB; do not combine routinely with an ACE inhibitor. | Initial 20 mg/day; maximum 40 mg once daily. | Hyperkalemia, hypotension, renal dysfunction; reported angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Telmisartan Micardis, generics | Once-daily ARB; do not combine routinely with an ACE inhibitor. | Initial and usual 80 mg once daily. | Hyperkalemia, hypotension, renal dysfunction; reported angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
| Valsartan Diovan, generics | Once-daily ARB; do not combine routinely with an ACE inhibitor. | Initial 80 mg/day; usual 80-320 mg once daily. | Hyperkalemia, hypotension, renal dysfunction; reported angioedema. | Potassium-retaining drugs, NSAIDs and lithium; monitor serum creatinine and potassium. |
Beta-adrenergic antagonists - nonselective
Not first-line solely for uncomplicated hypertension; retain for a compelling indication such as angina, post-myocardial infarction, selected heart failure or rate/rhythm control. Fatigue, bradycardia, reduced exercise capacity, headache, sexual dysfunction, sleep effects, depression, heart failure and heart block may occur. Avoid in asthma, severe peripheral arterial disease and unpaced second- or third-degree block. Digoxin, non-dihydropyridine calcium-channel blockers and amiodarone add bradycardia or cardiac depression. Never stop abruptly; taper to avoid rebound hypertension and ischemia.<cite data-reference-id="9e03152a-78c4-47ea-c742-87a706baf525"></cite>
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Nadolol generics | Nonselective beta-blocker for a specific clinical indication. | Initial 20 mg/day; usual 160 mg/day; maximum 320 mg once daily. | Fatigue, bradycardia, reduced exercise tolerance, vivid dreams, depression, heart block. | Additive bradycardia with digoxin, diltiazem, verapamil or amiodarone. |
| Propranolol controlled-release; generics | Lipid soluble; CNS effects such as insomnia, depression and vivid dreams may be more prominent. | Controlled-release: initial 80 mg/day; usual 320 mg/day; maximum 480 mg once daily. | Fatigue, bradycardia, exercise intolerance, CNS and sexual adverse effects. | CYP2D6 inhibitors raise levels; raises rizatriptan levels; additive cardiac depression with rate-slowing drugs. |
| Timolol generics | Nonselective beta-blocker for a specific clinical indication. | Initial 5 mg BID; usual 20 mg BID; maximum 30 mg BID. | Fatigue, bradycardia, reduced exercise tolerance, vivid dreams, depression, heart block. | Additive bradycardia with digoxin, diltiazem, verapamil or amiodarone. |
Beta1-selective adrenergic antagonists
Cardioselectivity can reduce, but does not eliminate, noncardiac beta-blocker effects. Use for a compelling indication rather than initial uncomplicated hypertension. Apply the same heart-block, asthma, peripheral arterial disease and gradual-withdrawal precautions as other beta-blockers.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Atenolol Tenormin, generics | Beta1-selective agent for a compelling indication. | Initial 25 mg/day; usual 50 mg/day; maximum 100 mg/day, once daily or divided BID. | Fatigue, bradycardia, reduced exercise tolerance, headache, sexual dysfunction, heart block. | Additive bradycardia with digoxin, non-dihydropyridine CCBs or amiodarone. |
| Bisoprolol generics | Beta1-selective agent for a compelling indication. | Initial 5 mg/day; usual 10 mg/day; maximum 20 mg once daily. | Fatigue, bradycardia, reduced exercise tolerance, headache, sexual dysfunction, heart block. | Additive bradycardia with digoxin, non-dihydropyridine CCBs or amiodarone. |
| Metoprolol generics | Beta1-selective agent for a compelling indication; formulation determines frequency. | Initial 50 mg/day; usual 100-200 mg/day; maximum 400 mg/day. Immediate-release BID; sustained-release once daily. | Fatigue, bradycardia, reduced exercise tolerance, headache, sexual dysfunction, heart block. | CYP2D6 inhibitors increase metoprolol; rate-slowing drugs add bradycardia. |
| Nebivolol Bystolic | Beta1-selective agent for a compelling indication. | Initial 5 mg/day; usual 10 mg/day; maximum 20 mg once daily. | Fatigue, bradycardia, reduced exercise tolerance, headache, sexual dysfunction, heart block. | CYP2D6 inhibitors increase nebivolol; rate-slowing drugs add bradycardia. |
Beta-adrenergic antagonists with intrinsic sympathomimetic activity
Agents with intrinsic sympathomimetic activity have less effect on resting heart rate, but retain class precautions and are not preferred first-line antihypertensives.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Pindolol Visken, generics | Nonselective beta-blocker with intrinsic sympathomimetic activity. | Initial 5 mg BID; usual 15 mg BID; maximum 60 mg/day. | Fatigue, bradycardia, reduced exercise tolerance, vivid dreams, depression, heart block. | Additive bradycardia and cardiac depression with digoxin, non-dihydropyridine CCBs or amiodarone. |
| Acebutolol generics | Beta1-selective beta-blocker with intrinsic sympathomimetic activity. | Initial 100 mg/day; usual 400 mg/day; maximum 800 mg/day, once daily or divided BID. | Fatigue, bradycardia, reduced exercise tolerance, vivid dreams, depression, heart block. | Additive bradycardia and cardiac depression with digoxin, non-dihydropyridine CCBs or amiodarone. |
Beta-adrenergic antagonist with alpha1-blocking activity
Labetalol combines beta blockade with alpha1 blockade. In addition to beta-blocker risks, edema, dizziness, nasal congestion and postural hypotension may occur.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Labetalol generics | Combined alpha1 and beta blockade; use according to the clinical indication. | Initial 50 mg BID; usual 200 mg BID; maximum 1200 mg/day. | Fatigue, bradycardia, heart block, edema, dizziness, nasal congestion, postural hypotension. | Digoxin, non-dihydropyridine CCBs and amiodarone add bradycardia or cardiac depression. |
Calcium-channel blockers - dihydropyridine
Long-acting dihydropyridines are complementary first-line options. Ankle edema, flushing, headache and palpitations are common. These agents are CYP3A4 substrates; azole antifungals, protease inhibitors, macrolides, quinidine and grapefruit can raise concentrations.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Amlodipine Norvasc, generics | Long-acting first-line dihydropyridine option. | Initial 2.5 mg/day; maximum 10 mg once daily. | Ankle edema, flushing, headache, palpitations. | CYP3A4 inhibitors can increase exposure. |
| Felodipine extended-release; Plendil, generics | Use the extended-release formulation. | Initial 2.5 mg/day; usual 10 mg/day; maximum 20 mg once daily. | Ankle edema, flushing, headache, palpitations. | Avoid grapefruit because it can markedly raise felodipine levels; CYP3A4 interactions. |
| Nifedipine extended-release; Adalat XL, generics | Use only a long-acting formulation for essential hypertension; do not use short-acting nifedipine. | Initial 30 mg/day; usual 60 mg/day; maximum 120 mg once daily. | Ankle edema, flushing, headache, palpitations. | CYP3A4 inhibitors and grapefruit can increase exposure. |
Calcium-channel blockers - nondihydropyridine
Diltiazem and verapamil slow heart rate and atrioventricular conduction. Headache, dizziness, bradycardia, heart block and new or worsening heart failure can occur. Avoid or use cautiously in heart failure or unpaced second- or third-degree block. Both are CYP3A4 substrates and inhibitors and can interact with beta-blockers, digoxin, amiodarone, carbamazepine, cyclosporine and some statins.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Diltiazem Tiazac, Tiazac XC, generics | Choose the formulation deliberately; not a complementary first-line dihydropyridine. | Initial 120 mg/day; usual 240-360 mg/day; maximum 360 mg/day. CD/XC once daily; SR divided BID. | Headache, dizziness, bradycardia, heart block, worsening heart failure. | CYP3A4 interactions; grapefruit may increase levels; additive bradycardia with beta-blockers or digoxin. |
| Verapamil Isoptin SR, generics | Rate-slowing nondihydropyridine; formulation determines frequency. | Immediate-release: initial 80 mg TID, maximum 160 mg TID. SR: initial 180 mg/day; usual 180-480 mg/day; maximum 480 mg/day once daily or divided BID. | Constipation, headache, dizziness, bradycardia, heart block, worsening heart failure. | CYP3A4 and P-glycoprotein interactions; additive bradycardia with beta-blockers or digoxin. |
Centrally acting antihypertensive agents
Not routine first-line therapy. Sedation, dry mouth, orthostatic hypotension and dizziness are common. Abrupt clonidine withdrawal can produce severe rebound hypertension; methyldopa requires attention to depression, liver, blood and fluid-retention adverse effects.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Clonidine generics | Reserve for selected add-on use and plan any discontinuation as a taper. | Initial 0.1 mg BID; usual 0.3 mg BID. | Sedation, dry mouth, orthostatic hypotension, dizziness. | Other CNS depressants and antihypertensives add effects; do not stop abruptly. |
| Methyldopa generics | Selected use, including pregnancy-specific pathways when appropriate. | Initial 500 mg/day; usual 2000 mg/day; maximum 3000 mg/day divided BID-TID. | Drowsiness, dry mouth, depression, orthostasis, sexual dysfunction, sodium/water retention; hepatic or hematologic reactions. | Other CNS depressants and antihypertensives add effects; monitor clinically appropriate liver and blood parameters. |
Potassium-sparing diuretics
Not initial monotherapy. Hyperkalemia risk rises with kidney impairment, potassium supplements, ACE inhibitors, ARBs, aliskiren and NSAIDs. Monitor serum creatinine and potassium.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Amiloride Midamor | Potassium-sparing add-on; avoid with significant renal impairment or hyperkalemia. | Initial 5 mg/day; usual 10 mg once daily. | Hyperkalemia, muscle cramps, headache, gastrointestinal symptoms. | Avoid or closely manage NSAIDs and other potassium-raising drugs. |
| Spironolactone Aldactone, generics | Preferred fourth-line consideration for confirmed resistant hypertension when appropriate.<cite data-reference-id="c136485d-abf7-4a1d-fa75-bada39ed2858"></cite> | Initial 25 mg/day; usual 100 mg once daily. | Hyperkalemia, gynecomastia, breast tenderness, anti-androgen effects, gastrointestinal symptoms. | ACE inhibitors, ARBs, potassium, NSAIDs and renal impairment raise hyperkalemia risk; monitor potassium after initiation and dose changes. |
Thiazide and thiazide-like diuretics
First-line complementary options. Hypotension, weakness, cramps, sexual dysfunction, hypokalemia, hyponatremia, hyperuricemia, dysglycemia and lipid changes can occur; uncommon effects include azotemia, blood dyscrasias, sulfonamide-type reactions, fatigue and photosensitivity. Lithium excretion falls, NSAIDs reduce pressure response, hypokalemia increases digoxin toxicity, and glucose-lowering drug response may be reduced. Monitor serum creatinine, sodium and potassium; consider gout, diabetes and arrhythmia risk. Standard thiazides become less effective at low kidney function.<cite data-reference-id="af14263b-89d5-48fb-d853-98b817cb0636"></cite>
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Hydrochlorothiazide generics | Thiazide option; particularly effective for isolated systolic hypertension and in older or Black adults. | Initial 12.5 mg/day; usual 25 mg once daily. | Electrolyte depletion, hypotension, hyperuricemia, dysglycemia, photosensitivity. | Lithium, NSAIDs, digoxin and glucose-lowering therapy; monitor kidney function and electrolytes. |
| Chlorthalidone generics | Long-acting thiazide-like option; hypokalemia may be more frequent than with hydrochlorothiazide. | Initial 12.5 mg/day; usual 12.5-25 mg once daily. | Electrolyte depletion, hypotension, hyperuricemia, dysglycemia, photosensitivity. | Lithium, NSAIDs, digoxin and glucose-lowering therapy; monitor kidney function and electrolytes. |
| Indapamide generics | Thiazide-like option. | Initial 1.25 mg/day; usual 2.5 mg once daily. | Electrolyte depletion, hypotension, hyperuricemia, dysglycemia, photosensitivity. | Lithium, NSAIDs, digoxin and glucose-lowering therapy; monitor kidney function and electrolytes. |
| Metolazone Zaroxolyn | Thiazide-like option requiring close volume and electrolyte monitoring. | Initial 2.5 mg/day; usual 5 mg/day; maximum 10 mg once daily. | Electrolyte depletion, hypotension, hyperuricemia, dysglycemia, photosensitivity. | Lithium, NSAIDs, digoxin and glucose-lowering therapy; monitor kidney function and electrolytes. |
ACE inhibitor/calcium-channel blocker combination
Fixed-dose products retain all component contraindications, adverse effects, interactions and monitoring. Avoid ACE-inhibitor combinations in pregnancy.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Amlodipine / Perindopril arginine Viacoram, generics | Complementary ACE inhibitor plus dihydropyridine CCB in one tablet. | Initial 3.5/2.5 mg once daily; usual 7/5 mg once daily; maximum 14/10 mg once daily. | Cough, edema, headache, hypotension, hyperkalemia, renal dysfunction; rare angioedema. | ACE-inhibitor potassium/NSAID/lithium interactions plus amlodipine CYP3A4 interactions; monitor kidney function and potassium. |
ACE inhibitor/diuretic combinations
Fixed-dose products combine ACE-inhibitor and thiazide/thiazide-like effects. Avoid in pregnancy. Monitor kidney function, sodium and potassium; review potassium products, NSAIDs, lithium, gout, diabetes and volume status.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Cilazapril / Hydrochlorothiazide Inhibace Plus, generics | Fixed-dose ACE inhibitor/thiazide. | 5/12.5 mg once daily. | Cough, hypotension, renal dysfunction and electrolyte/metabolic effects; rare angioedema. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Enalapril / Hydrochlorothiazide Vaseretic, generics | Fixed-dose ACE inhibitor/thiazide. | 5/12.5 mg or 10/25 mg once daily. | Cough, hypotension, renal dysfunction and electrolyte/metabolic effects; rare angioedema. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Lisinopril / Hydrochlorothiazide Zestoretic, generics | Fixed-dose ACE inhibitor/thiazide. | 10/12.5 mg, 20/12.5 mg or 20/25 mg once daily. | Cough, hypotension, renal dysfunction and electrolyte/metabolic effects; rare angioedema. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Perindopril / Indapamide Coversyl Plus, Coversyl Plus LD/HD, generics | Fixed-dose ACE inhibitor/thiazide-like diuretic. | 2/0.625 mg, 4/1.25 mg or 8/2.5 mg once daily. | Cough, hypotension, renal dysfunction and electrolyte/metabolic effects; rare angioedema. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Quinapril / Hydrochlorothiazide generics | Fixed-dose ACE inhibitor/thiazide. | 10/12.5 mg, 20/12.5 mg or 20/25 mg once daily. | Cough, hypotension, renal dysfunction and electrolyte/metabolic effects; rare angioedema. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Ramipril / Hydrochlorothiazide Altace HCT, generics | Fixed-dose ACE inhibitor/thiazide. | 2.5/12.5 mg, 5/12.5 mg, 10/12.5 mg, 5/25 mg or 10/25 mg once daily. | Cough, hypotension, renal dysfunction and electrolyte/metabolic effects; rare angioedema. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
ARB/diuretic combinations
Fixed-dose products combine ARB and thiazide/thiazide-like effects. Avoid in pregnancy. Monitor kidney function, sodium and potassium; review potassium products, NSAIDs, lithium, gout, diabetes and volume status.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Azilsartan medoxomil / Chlorthalidone Edarbyclor | Fixed-dose ARB/thiazide-like diuretic. | 40/12.5 mg, 40/25 mg or 80/12.5 mg once daily. | Hypotension, renal dysfunction, hyperuricemia and electrolyte/metabolic effects. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Candesartan cilexetil / Hydrochlorothiazide Atacand Plus, generics | Fixed-dose ARB/thiazide. | 16/12.5 mg once daily. | Hypotension, renal dysfunction, hyperuricemia and electrolyte/metabolic effects. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Irbesartan / Hydrochlorothiazide Avalide, generics | Fixed-dose ARB/thiazide. | 150/12.5 mg or 300/12.5 mg once daily. | Hypotension, renal dysfunction, hyperuricemia and electrolyte/metabolic effects. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Losartan / Hydrochlorothiazide Hyzaar, Hyzaar DS, generics | Fixed-dose ARB/thiazide. | 50/12.5 mg or 100/25 mg once daily. | Hypotension, renal dysfunction, hyperuricemia and electrolyte/metabolic effects. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Olmesartan medoxomil / Hydrochlorothiazide Olmetec Plus, generics | Fixed-dose ARB/thiazide. | 20/12.5 mg, 40/12.5 mg or 40/25 mg once daily. | Hypotension, renal dysfunction, hyperuricemia and electrolyte/metabolic effects. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Telmisartan / Hydrochlorothiazide Micardis Plus, generics | Fixed-dose ARB/thiazide. | 80/12.5 mg or 80/25 mg once daily. | Hypotension, renal dysfunction, hyperuricemia and electrolyte/metabolic effects. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
| Valsartan / Hydrochlorothiazide Diovan-HCT, generics | Fixed-dose ARB/thiazide. | 80/12.5 mg, 160/12.5 mg or 160/25 mg once daily. | Hypotension, renal dysfunction, hyperuricemia and electrolyte/metabolic effects. | Potassium, NSAIDs and lithium; monitor kidney function and electrolytes. |
Beta-blocker/diuretic combinations
These fixed-dose products combine beta-blocker and thiazide/thiazide-like adverse effects and interactions. They are not preferred initial therapy for uncomplicated hypertension; avoid abrupt beta-blocker withdrawal and monitor kidney function and electrolytes.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Atenolol / Chlorthalidone generics | Fixed-dose beta1-selective blocker/thiazide-like diuretic. | 50/25 mg or 100/25 mg once daily. | Bradycardia, fatigue, hypotension, electrolyte depletion, hyperuricemia and dysglycemia. | Rate-slowing drugs, lithium, NSAIDs, digoxin and glucose-lowering therapy. |
| Pindolol / Hydrochlorothiazide Viskazide | Fixed-dose beta-blocker with ISA/thiazide. | 10/25 mg or 10/50 mg once daily. | Bradycardia, fatigue, hypotension, electrolyte depletion, hyperuricemia and dysglycemia. | Rate-slowing drugs, lithium, NSAIDs, digoxin and glucose-lowering therapy. |
Calcium-channel blocker/ARB combination
This complementary fixed-dose pairing retains ARB pregnancy, kidney and potassium precautions plus dihydropyridine edema and CYP3A4 considerations.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Amlodipine / Telmisartan Twynsta | Fixed-dose long-acting dihydropyridine/ARB. | 5/40 mg, 5/80 mg, 10/40 mg or 10/80 mg once daily. | Edema, flushing, headache, hypotension, hyperkalemia and renal dysfunction. | Potassium-retaining drugs, NSAIDs and CYP3A4 inhibitors; monitor kidney function and potassium. |
Calcium-channel blocker/HMG-CoA reductase inhibitor combination
This product treats blood pressure and a lipid indication in one tablet; select each component dose independently and retain all amlodipine and atorvastatin precautions.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Amlodipine / Atorvastatin Caduet, generics | Use only when both the antihypertensive and statin components are indicated. | Amlodipine 5 or 10 mg plus atorvastatin 10, 20, 40 or 80 mg once daily. | Edema, flushing, headache; statin-associated muscle, hepatic and gastrointestinal effects. | CYP3A4 inhibitors and grapefruit can raise component exposure; review statin interactions. |
Diuretic combinations
These products pair hydrochlorothiazide with a potassium-sparing diuretic. They can reduce thiazide-associated potassium loss but can cause hyperkalemia, especially with kidney impairment or other potassium-raising therapy. Continue sodium, potassium and kidney-function monitoring.
| Drug | Clinical place and precautions | Adult oral dosing | Adverse effects | Interactions and monitoring |
|---|---|---|---|---|
| Amiloride / Hydrochlorothiazide 50/5 mg; generics | Fixed-dose thiazide/potassium-sparing diuretic. | One-half tablet once daily. | Hypotension, cramps, sodium disturbance, hyperuricemia, dysglycemia; potassium may rise or fall. | ACE inhibitors, ARBs, potassium, NSAIDs, lithium and digoxin; monitor kidney function and electrolytes. |
| Hydrochlorothiazide / Triamterene 25/50 mg; generics | Fixed-dose thiazide/potassium-sparing diuretic. | Initial one-half tablet once daily; usual one tablet once daily. | Hypotension, cramps, sodium disturbance, hyperuricemia, dysglycemia; potassium may rise or fall. | ACE inhibitors, ARBs, potassium, NSAIDs, lithium and digoxin; monitor kidney function and electrolytes. |
| Hydrochlorothiazide / Spironolactone 25/25 mg; generics | Fixed-dose thiazide/aldosterone-antagonist combination. | Initial one-half tablet once daily; usual one tablet once daily. | Hypotension, sodium disturbance, hyperuricemia, dysglycemia, hyperkalemia, gynecomastia. | ACE inhibitors, ARBs, potassium, NSAIDs, lithium and digoxin; monitor kidney function and electrolytes. |
Evidence note: The drug inventory, doses, adverse effects, interactions and product groupings were independently rewritten from the supplied Canadian pharmacist table. Guideline positioning and sequencing follow the 2025 Hypertension Canada guideline and its cited evidence.[8][2][4][5][9][10][6][7]
References
- Recommendations: 2025 Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care — Hypertension Canada. 2025
- Hypertension Canada guideline for the diagnosis and treatment of hypertension in adults in primary care — CMAJ and Hypertension Canada. CMAJ 2025;197:E549-E564. doi:10.1503/cmaj.241770
- Blood pressure devices and measurement resources — Hypertension Canada. Current guideline resources
- Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials — BMJ. 2003;326:1427
- Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis — The Lancet. 2016;387:957-967
- Adherence to single-pill versus free-equivalent combination therapy in hypertension: a systematic review and meta-analysis — Hypertension. 2021;77:692-705
- Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2) — The Lancet. 2015;386:2059-2068
- Hypertension: Table 6, Drugs Used for Hypertension — Canadian Pharmacists Association. CPS Therapeutic Choices. Revised January 6, 2026
- Beta-blockers for hypertension — Cochrane Database of Systematic Reviews. 2017;1:CD002003
- Chlorthalidone vs. hydrochlorothiazide for hypertension-cardiovascular events — New England Journal of Medicine. 2022;387:2401-2410
Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.