Hypertension

Sustained office blood pressure of 140/90 mm Hg or higher (ESC 2024) or 130/80 mm Hg or higher (ACC/AHA 2017) in adults. Treatment reduces the risk of stroke, myocardial infarction, and cardiovascular death.

ICD-10 I1047 drugs

Also known as: Essential hypertension, High blood pressure

Drugs used for this condition

AAmlodipineFirst line · Calcium channel blockers (dihydropyridines)Amlodipine is a dihydropyridine calcium channel blocker, a first-line class for hypertension. ESC 2024 names four first-line classes: ACE inhibitors, ARBs, dihydropyridine CCBs and thiazide or thiazide-like diuretics; ESH 2023 adds beta-blockers. For most patients with blood pressure of 140/90 mmHg or higher, these documents and the Spanish SEH-LELHA 2022 guideline advise starting with a single-pill combination: a RAAS blocker plus a dihydropyridine CCB or a diuretic. In patients of African origin, CCBs and thiazides are preferred over RAAS blockers (ESH 2023). In the ALLHAT trial amlodipine matched chlorthalidone and lisinopril on coronary outcomes, but heart failure was more frequent (10.2% vs 7.7%). Dose per the AEMPS label: 5 mg once daily, maximum 10 mg; in children aged 6–17 years 2.5–5 mg. Contraindications: severe hypotension, shock, severe aortic stenosis, haemodynamically unstable heart failure after myocardial infarction. Common adverse reactions: ankle oedema (dose-dependent), flushing, headache, palpitations. CYP3A4 inhibitors (clarithromycin, azole antifungals, diltiazem, verapamil) raise amlodipine exposure; simvastatin should not exceed 20 mg when combined. In pregnancy it is not a first-line drug: labetalol, methyldopa and nifedipine are preferred; 3–7% of the maternal dose passes into breast milk. It is not used for hypertensive emergencies.
AAmlodipine + OlmesartanFirst line · Fixed-dose combination: dihydropyridine calcium channel blocker plus angiotensin II receptor blockerEssential hypertension in adults. Per ESC 2024 (Class I), ESH 2023 and the Spanish SEH-LELHA 2022 guideline, most patients with confirmed hypertension start treatment with two drugs in a single pill; a renin-angiotensin-aldosterone system blocker (RAAS blocker, here olmesartan) with a dihydropyridine calcium channel blocker (here amlodipine) is one of the two preferred starting pairs. Monotherapy is reserved for specific groups (very old or frail patients, orthostatic hypotension and, per ESH 2023, low-risk grade 1 hypertension). The Spanish SmPC (AEMPS) indicates the combination for adults whose blood pressure is not controlled on olmesartan or amlodipine monotherapy and allows a direct switch from monotherapy when clinically appropriate. ESC 2024 target: systolic BP 120–129 mmHg if well tolerated. In Spain the tablets are 20/5, 40/5 and 40/10 mg (olmesartan/amlodipine) once daily with or without food; the maximum effect is reached within the first 2 weeks. With creatinine clearance 20–60 mL/min and in moderate hepatic impairment olmesartan is capped at 20 mg/day; with clearance <20 mL/min the combination is not recommended. Contraindicated in the second and third trimesters of pregnancy (not recommended in the first), in severe hepatic impairment and biliary obstruction, severe hypotension, shock, severe aortic stenosis, unstable heart failure after acute myocardial infarction, and with aliskiren in diabetes or eGFR <60 mL/min/1.73 m²; not recommended during breastfeeding. Potassium and creatinine are monitored, especially in chronic kidney disease, heart failure and with potassium supplements or potassium-sparing diuretics; combination with lithium and dual RAAS blockade are not recommended. Olmesartan carries a risk of its own: very rare sprue-like enteropathy (SmPC warning, FDA 2013), severe chronic diarrhoea with weight loss after months or years of use; olmesartan is stopped and not restarted.
AAmlodipine + Olmesartan + HydrochlorothiazideSecond line · Triple fixed-dose combination: dihydropyridine CCB, angiotensin II receptor blocker, and thiazide diureticEssential hypertension in adults whose BP is not controlled on a dual combination. Per the Spanish label (CIMA 73437, section 4.1) it replaces Olmesartan + Amlodipine when BP is not controlled on that pair, or the same three components that a patient with controlled BP already takes as two tablets: one tablet instead of two for adherence. ESH 2023 and ESC 2024 place the triple combination of a RAS blocker + dihydropyridine CCB + thiazide at step two of the algorithm: start with a dual single-pill combination, and if BP is not controlled move to triple, ideally also in one pill. The label advises titrating the components first; a direct switch from dual to triple is acceptable when clinically appropriate. If BP stays at 140/90 or higher on triple therapy at maximally tolerated doses, that is resistant hypertension: check adherence and out-of-office BP, exclude secondary causes (renovascular hypertension, primary aldosteronism, pheochromocytoma) and add Spironolactone with potassium and creatinine monitoring. Target per SEH-LELHA 2022 and ESH 2023: <130/80 in most patients if well tolerated; ESC 2024 is stricter: systolic 120–129. The combination itself has an RCT, TRINITY (12 weeks, moderate to severe hypertension, triple combination vs dual combinations of the same components). Strengths (Amlodipine/Olmesartan/HCTZ): 5/20/12.5, 5/40/12.5, 5/40/25, 10/40/12.5, 10/40/25 mg once daily at the same time, with or without food; maximum 10/40/25. Safety (label 4.3–4.6): Hydrochlorothiazide raises the risk of non-melanoma skin cancer with cumulative dose – protect the skin from the sun, check it regularly, and reconsider the drug in patients with a history of skin cancer. Olmesartan very rarely causes sprue-like enteropathy: severe chronic diarrhea with weight loss months or years after starting; stop the drug if confirmed. Monitor potassium, sodium, calcium, uric acid and creatinine; HCTZ can cause choroidal effusion, acute myopia and angle-closure glaucoma. Contraindicated with CrCl <30 mL/min, refractory hypokalemia, hypercalcemia, hyponatremia, symptomatic hyperuricemia, severe hepatic impairment or cholestasis, sulfonamide allergy, shock, severe hypotension, high-grade aortic stenosis, hemodynamically unstable heart failure after myocardial infarction, and together with Aliskiren in diabetes or eGFR <60. With CrCl 30–60 mL/min or moderate hepatic impairment the maximum is 5/20/12.5 with potassium and creatinine monitoring; over 65, monitor BP more often; over 75, data are very limited. Pregnancy: contraindicated in the 2nd and 3rd trimesters, not recommended in the 1st; switch to another drug when planning pregnancy and stop at once if pregnancy occurs. Not recommended during breastfeeding. Interactions: Lithium (combination not recommended), NSAIDs (weaker effect, kidney function may worsen), potassium-sparing diuretics and potassium supplements, ACE inhibitors and Aliskiren (dual RAS blockade), CYP3A4 inhibitors (higher Amlodipine levels), Simvastatin no more than 20 mg per day.
AAmlodipine + ValsartanFirst line · Fixed-dose combination: dihydropyridine calcium channel blocker plus angiotensin II receptor blockerEssential hypertension. Per ESC 2024, ESH 2023 and SEH-LELHA 2022, most patients with confirmed hypertension (BP ≥140/90) start treatment with two drugs in a single pill, and a RAS blocker with a dihydropyridine CCB is one of the two preferred pairs (the other is a RAS blocker with a diuretic). ESC 2024 keeps monotherapy for patients aged 85 and over, with moderate or severe frailty, symptomatic orthostatic hypotension, or elevated BP of 120–139/70–89. The Spanish label indicates the combination for adults whose BP is uncontrolled on amlodipine or valsartan monotherapy and advises titrating the components first, but allows a direct switch from monotherapy. Dose (amlodipine/valsartan): 5/80, 5/160 or 10/160 mg once daily. Full effect at 2–4 weeks. Per the label, peripheral edema is overall less frequent on the combination than on amlodipine monotherapy (5.1% on average across doses), but at 10/160 the difference from amlodipine 10 mg is small: 9.0% vs 10.3%. Contraindicated in the second and third trimesters of pregnancy and not recommended in the first: patients planning pregnancy switch to another drug; not recommended during breastfeeding. Dual RAS blockade with an ACE inhibitor or aliskiren is not recommended, and the combination with aliskiren is contraindicated in patients with diabetes or eGFR <60 mL/min. Monitor potassium and creatinine in chronic kidney disease and with potassium-sparing diuretics, potassium supplements or potassium-containing salt substitutes. Anti-inflammatory painkillers (NSAIDs such as ibuprofen) blunt the effect and strain the kidneys. Lithium is not recommended with this drug, and if it cannot be avoided, lithium levels need close monitoring. CYP3A4 inhibitors raise amlodipine exposure, simvastatin no more than 20 mg daily. Contraindicated in severe hepatic impairment, biliary cirrhosis and cholestasis, severe hypotension and shock, severe aortic stenosis and obstructive hypertrophic cardiomyopathy, and in hemodynamically unstable heart failure after myocardial infarction.
AAmlodipine + Valsartan + HydrochlorothiazideSecond line · Triple fixed-dose combination: dihydropyridine CCB, angiotensin II receptor blocker, and thiazide diureticEssential hypertension when blood pressure control needs three drugs: an angiotensin II receptor blocker (ARB), a dihydropyridine calcium channel blocker and a thiazide diuretic. Per ESC 2024, ESH 2023 and the Spanish SEH-LELHA 2022 guideline, the triple combination, preferably as a single pill, is the second step when a dual combination has not brought blood pressure to target. If blood pressure stays above target on full doses of all three drugs, this is resistant hypertension: adherence is checked and secondary causes are excluded first, then spironolactone is added. In Spain the fixed-dose tablet is licensed as substitution therapy (AEMPS SmPC): the patient is first stabilised on the same three components taken separately or as a dual combination plus the third drug, then switched to the equivalent dose. Strengths 5/160/12.5, 10/160/12.5, 5/160/25, 10/160/25 and 10/320/25 mg once daily; the full effect at the maximum dose is reached after 2 weeks. In the registration randomised trial (Calhoun 2009, n=2271, 8 weeks; figures from the AEMPS SmPC) the 10/320/25 mg dose lowered blood pressure by 39.7/24.7 mmHg, 6.2–8.2/3.3–5.3 mmHg more than any of the three dual combinations; 71% reached blood pressure below 140/90 mmHg versus 45–54%. Contraindications: second and third trimesters of pregnancy, severe renal impairment (eGFR <30 mL/min), anuria and dialysis, hepatic impairment and cholestasis, refractory hypokalaemia, hyponatraemia and hypercalcaemia, symptomatic hyperuricaemia (gout), aliskiren in diabetes or eGFR <60, severe hypotension and shock, high-grade aortic stenosis and obstructive hypertrophic cardiomyopathy, haemodynamically unstable heart failure after myocardial infarction. Not recommended in the first trimester; women planning pregnancy are switched to another regimen in advance, and the drug is stopped as soon as pregnancy is confirmed; not recommended during breastfeeding. Hydrochlorothiazide raises the risk of non-melanoma skin cancer with cumulative dose (EMA PRAC assessment, AEMPS note 2018): sun protection, skin checks, and review of the prescription in patients with prior skin cancer. Monitor potassium, sodium, creatinine and uric acid: the thiazide can lower blood sodium and potassium and trigger a gout attack. Interactions: lithium (toxicity), potassium supplements and potassium-sparing diuretics, NSAIDs, ACE inhibitors or aliskiren (dual RAAS blockade), CYP3A4 inhibitors and grapefruit (amlodipine), simvastatin no higher than 20 mg/day.
AAzilsartan medoxomilFirst line · Angiotensin II receptor blockerAzilsartan is a sartan, an angiotensin II receptor blocker. The AEMPS Edarbi label gives it one indication: treatment of essential hypertension in adults. In the 2024 ESC guideline sartans sit in the first line alongside ACE inhibitors, calcium channel blockers and thiazide-like diuretics, and a regimen usually starts with two drugs at low dose. On 24-hour blood pressure reduction azilsartan 80 mg looks at least as good as other sartans in head-to-head work, but it has no outcome trials of its own: the choice within the class rests on data for losartan, valsartan, telmisartan and candesartan. The laboratory minimum at the start is potassium and creatinine at 1–2 weeks, because blocking the renin-angiotensin system raises potassium and can drop filtration. In Spain Edarbi holds an AEMPS authorisation but has not been marketed, so it is not on the pharmacy shelf.
AAzilsartan medoxomil + chlorthalidoneSecond line · Fixed-dose combination: angiotensin II receptor blocker with a thiazide-like diureticThe fixed combination of azilsartan with chlorthalidone covers hypertension through two mechanisms at once. The FDA Edarbyclor label describes two scenarios: moving a patient whose blood pressure was not held by monotherapy, and starting straight on the combination when a single drug clearly will not reach target. The starting dose is 40/12.5 mg once daily. The 2024 ESC guideline points the same way: treatment usually begins with two drugs at low dose, because target is reached faster and adherence runs higher than with stepwise addition. Laboratory follow-up is trickier than for a single agent: both components move potassium and the shift can go either way, so potassium, sodium and creatinine are checked 1–2 weeks after starting and after every dose change. In Spain this combination is not registered; in Russia it is sold as Edarbi Klo.
ACandesartanFirst line · Angiotensin II receptor blockerCandesartan lowers blood pressure and major cardiovascular events in adults. ESC 2024 and NICE NG136 list ARBs as first-line therapy for hypertension as monotherapy and in combination with a thiazide diuretic or calcium channel blocker. Once-daily dosing with 24-hour effect improves adherence compared with twice-daily losartan.
ACandesartan + HydrochlorothiazideSecond line · Fixed-dose combination: angiotensin II receptor blocker plus thiazide diureticEssential hypertension uncontrolled on candesartan monotherapy. Per ESH/ESC 2023 and SEH-LELHA 2023 – second-line. Dose: 8/12.5, 16/12.5, 32/12.5, 32/25 mg once daily. Full effect at 4 weeks. Candesartan reduces nocturnal BP more than most other ARBs, useful for the non-dipper profile on ABPM.
ACaptoprilSecond line · ACE inhibitorCaptopril lowers blood pressure in adults, with efficacy established by large ACE-inhibitor trials. ESC 2024 and NICE NG136 keep ACE inhibitors as first-line therapy for hypertension in patients under 55 years and not of Black ancestry. Among ACE inhibitors, captopril has been displaced by enalapril, lisinopril, and perindopril because of the need for 2–3 daily doses and the relatively high rate of skin rash. Today captopril is used mainly for sublingual treatment of hypertensive emergencies at 25 mg.
AChlortalidoneFirst line · Long-acting thiazide-like diureticChlorthalidone is a thiazide-like diuretic. The AEMPS Higrotona label puts arterial hypertension first among its indications, as monotherapy or in combination. The 2024 ESC guideline keeps thiazide-like diuretics in the first line beside ACE inhibitors, sartans and calcium channel blockers, and within the group it favours chlorthalidone and indapamide over hydrochlorothiazide: the long half-life covers night-time blood pressure in a way a short-acting drug does not. Working doses in hypertension are low, 12.5–25 mg daily, and pushing the dose adds more adverse effects than millimetres of mercury. Potassium and sodium are checked 1–2 weeks after starting, then every 4–6 months, and more often in older people, because hyponatraemia unfolds on day 5-14.
AEnalaprilFirst line · Angiotensin-converting enzyme inhibitors (ACEi)First-line antihypertensive per ESC/ESH 2024 and ACC/AHA 2017. Start at 5 mg once daily, titrate to 10–20 mg 1–2 times daily. Particularly preferred in comorbid T2D, CKD, HFrEF, and post-MI states. In Black patients, monotherapy is less effective; CCBs or thiazide-like diuretics are often chosen.
AEnalapril + HydrochlorothiazideSecond line · Fixed-dose combination: ACE inhibitor plus thiazide diureticEssential hypertension uncontrolled on enalapril monotherapy. Per ESH/ESC 2023 and SEH-LELHA 2023, ACE inhibitor + thiazide is a well-proven second-line pair with long-term outcome data (HOPE, PROGRESS). Dose: 10/25, 20/12.5, 20/25 mg once daily. Full effect at 2–4 weeks. In Black patients, ACE inhibitor efficacy is lower than CCBs or thiazides in monotherapy, but the thiazide component of the combination compensates.
AHydrochlorothiazideFirst line · Thiazide diureticsHydrochlorothiazide is a first-line antihypertensive alongside ACE inhibitors, ARBs, and calcium channel blockers. Recommended by ESC/ESH 2024, ACC/AHA 2017, and JNC 8. Stroke and cardiovascular event reduction is confirmed in classic trials ALLHAT, SHEP, and MRFIT. Current European and UK guidelines often prefer thiazide-like diuretics (indapamide, chlorthalidone) when choosing a thiazide due to a smoother 24-hour effect.
AIndapamideFirst line · Thiazide-like diureticsIndapamide is the preferred thiazide-like diuretic per ESC/ESH 2024 and NICE. Dose 1.5 mg (sustained release) or 2.5 mg (immediate release) once daily. Antihypertensive efficacy is comparable to amlodipine and ACE inhibitors. Metabolically preferable to hydrochlorothiazide – less impact on potassium, glucose, and lipids.
AIrbesartanFirst line · Angiotensin II receptor blocker (ARB, sartan)First-line for hypertension per ESC/ESH 2024. Dose 150–300 mg once daily. Particularly effective in patients with type 2 diabetes and nephropathy – IDNT (2001) showed 33% slowing of diabetic nephropathy progression vs amlodipine.
AIrbesartan + HydrochlorothiazideSecond line · Fixed-dose combination: angiotensin II receptor blocker plus thiazide diureticEssential hypertension uncontrolled on irbesartan monotherapy. Per ESH/ESC 2023 and SEH-LELHA 2023 – second-line. Dose: 150/12.5, 300/12.5, 300/25 mg once daily. Full effect at 6–8 weeks. Especially useful in patients with hypertension and type 2 diabetes due to irbesartan's renoprotective effect.
ALercanidipineFirst line · Third-generation dihydropyridine calcium channel blockerFirst-line for hypertension per ESC/ESH 2024. Dose 10–20 mg once daily. Particularly suitable in older patients and isolated systolic hypertension. Compared with amlodipine, less peripheral edema – an important advantage in women and with ACE-I or ARB combinations.
ALisinoprilFirst line · ACE inhibitorsFirst-line for hypertension per ESC/ESH 2023 and Spanish SEH-LELHA 2022. Starting dose 10 mg once daily, target 20–40 mg. Effective in patients with heart failure, post-MI, diabetic nephropathy. In Afro-Caribbean patients monotherapy is less effective than CCB or thiazide – ESC 2023 recommends combination.
ALosartanFirst line · Angiotensin II receptor blockers (sartans)Losartan is a first-line antihypertensive. Start at 50 mg once daily, maximum 100 mg. Prescribed as an alternative to ACE inhibitors, especially when ACEi-induced cough develops. The LIFE trial showed losartan superior to atenolol for stroke risk reduction in patients with hypertension and LVH.
ALosartan + HydrochlorothiazideSecond line · Fixed-dose combination: angiotensin II receptor blocker plus thiazide diureticEssential hypertension uncontrolled on losartan monotherapy. Per ESH/ESC 2023 and SEH-LELHA 2023 – second-line. Dose: 50/12.5, 100/12.5, 100/25 mg once daily. Full effect at 3 weeks. Losartan's uricosuric effect makes the combination acceptable in patients with prior gout (with caution), unlike other ARB-thiazide pairs.
AManidipineFirst line · Calcium channel blockers, dihydropyridineStage 1–2 hypertension. Starting dose 10 mg once daily in the morning; up-titrate to 20 mg after 2–4 weeks. More effective in combination with an ACE inhibitor or ARB – Spanish SEH-LELHA 2022 recommends combination therapy from the start for BP >=160/100 or high-risk patients. Not validated for post-MI protection or heart failure (unlike ACE inhibitors).
ANebivololFirst line · Highly selective β1-blocker with endothelial nitric oxide releaseIn hypertension, β-blockers are no longer universal first-line per ESC/ESH 2024 – they are preferred when comorbid indications exist (CAD, HF, tachyarrhythmia). Among β-blockers, nebivolol has the most favorable metabolic profile, with less weight gain and glucose intolerance. Standard dose 5 mg once daily; start at 2.5 mg in older adults.
AOlmesartan + HydrochlorothiazideSecond line · Fixed-dose combination: angiotensin II receptor blocker plus thiazide diureticEssential hypertension uncontrolled on olmesartan monotherapy. Per ESH/ESC 2023 and SEH-LELHA 2023 – second-line. Dose: 20/12.5, 20/25, 40/12.5, 40/25 mg once daily in the morning. Full effect at 2–4 weeks. Baseline creatinine, K+, Na+, uric acid; correct hypokalemia before initiation.
AOlmesartan medoxomilFirst line · Angiotensin II receptor blocker (ARB, sartan)First-line for hypertension under ESC/ESH 2024. Antihypertensive effect is comparable to other ARBs and ACE inhibitors. Standard dose 20 mg once daily; up-titrate to 40 mg if needed. Particularly suitable when hypertension coexists with diabetes, proteinuria, CKD, or metabolic syndrome.
APerindopril + IndapamideSecond line · Fixed-dose combination: ACE inhibitor plus thiazide-like diureticEssential hypertension uncontrolled on perindopril monotherapy. Per ESH/ESC 2023 and SEH-LELHA 2023 – second-line. Per HYVET 2008, particularly useful in patients over 80 (21% mortality reduction over 1.8 years). Dose: 2.5/0.625, 5/1.25, 10/2.5 mg once daily in the morning on an empty stomach. Full effect at 4 weeks.
ARamiprilFirst line · Angiotensin-converting enzyme inhibitor (ACE-I)First-line for hypertension per ESC/ESH 2024. Dose 2.5–10 mg once daily. Particularly effective with concomitant T2D, HF, CKD, or post-MI. HOPE trial showed 22% reduction in cardiovascular events in high-risk patients.
ATelmisartan + HydrochlorothiazideSecond line · Fixed-dose combination: angiotensin II receptor blocker plus thiazide diureticEssential hypertension uncontrolled on telmisartan monotherapy. Per ESH/ESC 2023 and SEH-LELHA 2023 – second-line. Dose: 40/12.5, 80/12.5, 80/25 mg once daily in the morning. Full effect at 4–8 weeks. Telmisartan fits the non-dipper pattern and morning BP surge (24-h T½).
AValsartanFirst line · Angiotensin II receptor blockers (ARBs)First-line antihypertensive. Starting dose 80 mg once daily, maximum 320 mg. Prescribed as an ACE inhibitor alternative or when ACEi is not tolerated (cough). Frequently included in fixed-dose combinations with amlodipine and/or hydrochlorothiazide. Antihypertensive effect develops over 2–4 weeks.
AValsartan + HydrochlorothiazideSecond line · Fixed-dose combination: angiotensin II receptor blocker plus thiazide diureticEssential hypertension when BP is not normalized on valsartan monotherapy. Per ESH/ESC 2023 and SEH-LELHA 2023 – second-line. Dose: 80/12.5, 160/12.5, 160/25, 320/12.5, 320/25 mg once daily. Full effect at 2–4 weeks. Do not combine with aliskiren in diabetes or CrCl <60 (AKI and hyperkalemia risk).
BAtenololSecond line · Selective beta-1 adrenergic blockerHypertension. Per ESC/ESH 2023 and SEH-LELHA 2022, atenolol is not first-line (LIFE 2002 trial showed inferiority to losartan in elderly cardiovascular outcomes). Used in CHD with tachycardia or beta-blocker intolerance. Dose 25–100 mg once daily.
BBisoprololCase-by-case decision · Selective beta-adrenergic blockersBeta-blockers as antihypertensive monotherapy in the absence of CAD, HF, tachyarrhythmia, or post-MI status are not first-line per ESC/ESH 2024, ACC/AHA 2017, and NICE NG136. In younger patients without a compelling indication, ACEi/ARB, CCB, or thiazide-like diuretic is preferred. ESC/ESH 2024 explicitly notes that beta-blockers are less effective at stroke prevention than other classes. Bisoprolol as first-line antihypertensive is justified only in concurrent CAD, HF, AF, or tachyarrhythmia. Dose 5–10 mg once daily.
BEplerenoneSecond line · Selective mineralocorticoid receptor antagonistUsed in resistant hypertension as a fourth drug (ACEi/ARB + calcium channel blocker + thiazide) per ESC/ESH 2024. Particularly effective in primary aldosteronism and low-renin hypertension. Dose 25–50 mg daily.
BFurosemideSecond line · Loop diureticsFor ordinary hypertension, furosemide is rarely prescribed and not recommended as a first choice. ESC/ESH 2024, ACC/AHA 2017, and NICE NG136 prefer thiazide-like diuretics (indapamide, chlorthalidone) because of a smoother antihypertensive effect and less potassium loss. Furosemide is used in hypertensive patients with marked HF or impaired renal function (eGFR < 30).
BMetoprololCase-by-case decision · Selective β1-adrenoceptor blockersBeta-blockers as antihypertensive monotherapy in the absence of CAD, HF, tachyarrhythmia, or post-MI status are not first-line per ESC/ESH 2024, ACC/AHA 2017, and NICE NG136. Metoprolol is prescribed in concurrent CAD, post-MI, or tachyarrhythmias. Less effective for stroke prevention than ACEi/ARB, CCB, or diuretics. Tartrate 50–100 mg twice daily or succinate 50–200 mg once daily. In younger patients without a compelling indication, other classes are preferred.
BMoxonidineThird line · Centrally acting antihypertensive, imidazoline I1 receptor agonistMoxonidine is a centrally acting antihypertensive. The AEMPS Moxon label gives it one indication: treatment of arterial hypertension. It lowers blood pressure reliably, but moxonidine has no large outcome trials covering myocardial infarction, stroke or death, so the 2024 ESC hypertension guideline places centrally acting sympatholytics behind the five main classes: ACE inhibitors, ARBs, calcium channel blockers, thiazide-like diuretics and beta blockers. Its practical niche sits elsewhere – once the main classes are exhausted or poorly tolerated. Titration starts at 0.2 mg daily, with a lower ceiling once renal filtration falls below 60 ml/min. Withdrawal takes two weeks rather than one day, and when a beta blocker runs alongside, the beta blocker goes first.
BPropranololAdd-on therapy · Non-selective beta blockerPropranolol is a non-selective beta-blocker, lowers blood pressure, and hypertension is among its registered indications. But for uncomplicated hypertension beta-blockers are not the first choice (ACE inhibitors/ARBs, dihydropyridine CCBs, and thiazide-like diuretics are preferred); beta-blockers are added for specific indications such as coronary disease, heart failure, arrhythmias, or after myocardial infarction. Propranolol itself is rarely used for primary hypertension, more often for tremor, migraine prophylaxis, and portal hypertension. Do not stop it abruptly.
BSpironolactoneAdd-on therapy · Potassium-sparing diuretics (mineralocorticoid receptor antagonists)In the general hypertensive population, spironolactone is not a first-line agent. Therapy is built on ACEi/ARB, calcium channel blockers, and thiazide-like diuretics. Spironolactone is considered as the fourth agent in resistant forms (see separate indication) and as the therapy of choice in primary aldosteronism.
BTorasemideSecond line · Loop diuretic – sulfonamide derivativeSecond-line for hypertension in patients with concomitant HF or CKD per ESC/ESH 2024, when thiazides are ineffective. Dose 2.5–5 mg once daily.
BVerapamilSecond line · Non-dihydropyridine calcium channel blockerVerapamil is a non-dihydropyridine calcium channel blocker that lowers blood pressure and is among the antihypertensive agents (ESC/ESH). For uncomplicated hypertension the preferred CCBs are dihydropyridines (amlodipine); verapamil is chosen when rate control is also needed (for example, with tachyarrhythmia). Do not combine with beta-blockers (risk of bradycardia and heart block); common adverse effects are constipation and edema.
CDoxazosinSecond line · Long-acting selective α1-adrenoceptor antagonistIn hypertension, α-blockers are no longer universal first-line per ESC/ESH 2024 after ALLHAT (2000) showed doxazosin inferior to chlorthalidone on heart failure. Used as a fourth drug in resistant hypertension or with concomitant BPH. Dose 4–8 mg once daily.

Marketing claims without evidence base

The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.

How to read tiers A–F

Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.

AStrong evidence – first or second line in international guidelines
BRecommended in selected cases
CStudy data contradict each other
DBenefit not proven, no documented harm
FDocumented harm, or risk without benefit