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292 Cardio Diabetes Medicine 2017

“The initial antihypertensive drug should be started at Individual class of drugs:
the lowest dose and gradually increased depending A. Diuretics:
on the BP response to the maximum tolerated dose.
If the anti hypertensive response to the initial drug is Decrease blood volume, decrease peripheral resis-
inadequate after reaching full dose (not necessarily tance and so BP.They are Very effective in elderly
maximum recommended dose), a second drug from with stiff peripheral artery. But at the same time caus-
another class should be added, provided the initial es increase of age related physiological changes and
drug is tolerated. If the person is having no thera- further depletion of blood volume, increase postural
peutic response or significant adverse effects, a drug hypotension. Electrolyte imbalance causing more ar-
from another class should be substituted. If a diuretic rhythmia. Impaired glucose tolerance, hyperuricae-
is not the initial drug, it is usually indicated as the mia, hypokalaemia. hypomagnesimia .But thiazide
second drug. If the antihyperten- sive response is diuretics maintain BMD and increase blood Calcium
inadequate after reaching the full dose of 2 classes level. Loop diuretics decrease blood Ca level.
of drugs, a third drug from another class should be B. Ca Channel blocker:
added. When the BP is 20/10 mm Hg above goal,
drug therapy should generally be initiated with 2 an- It is effective in elder population because of increased
tihypertensive drugs, 1 of which should be a thiazide vascular stiffness ,decreased vascular compliance ,
diuretic; however, in the elderly, treatment must be diastolic dysfunction . Adverse effects are postural
individualized .’’ hypotension, ankle edema, headache. These are ef-
fective in preventing dementia.
As per JNC 8,
C. ACEI and ARBs:
“In the general nonblack population, including those
with diabetes, initial antihypertensive treatment Reduce peripheral resistance without reflex stimula-
should include a thiazide-type diuretic, calcium chan- tion of HR and contractility.
nel blocker (CCB), angiotensin-converting enzyme in- Indications are HTN with HF / DM /Nephropathy/
hibitor (ACEI), or angiotensin receptor blocker (ARB). Post AMI/ Angina and also effective in preventing

Moderate Recommendation Grade B dementia.
In the general black population, including those with D. Beta Blocker:
diabetes, initial antihypertensive treatment should in- They are not used as first choice but used when Hy-
clude a thiazide-type diuretic or CCB. pertension associated with arrhythmias, Post AMI ,
For general black population: Moderate Recommen- Heart Failure, hyperthyroidism, essential tremor, anx-
dation – Grade B iety neurosis, preoperative hypertension.
For black patients with diabetes: Weak Recommen- Adherence is most important issue in eldely hyper-
dation – Grade C” tension. Frequent non-adherence and non-control
of BP occur due to dementia, Low socio-economic
As per Indian Hypertension Guidelines-III, condition, isolation, Cost, Side effects, Treating com-
Elderly hypertensives should be started with Calcium plications and all these issues are to be addressed
Channel blocker or Diuretic. while dealing a older hypertensive.

Summary of all guidelines: References:
- Start with small dose 1. Puspanjali S, TP Sherin Raj. Demography of aging in India. Indian Journal
of Gerontology 2005;19:327-42.
- Increase gradually with monitoring 2. Franlin SS, Jacobs MJ, Wong ND, L’Italian GL, Lapuerta P. Predominance
of isolated systolic hypertension among middle age and elderly US hyper-
- Add next drug if not controlled tensives analysis based on National Health and Nutrition Examination
- Observe side effects and drug interaction , non- Survey(NHANES) III. Hypertension 2001;37:869-74.
compliance 3. Franklin SS, Khan SA, Wong ND, Larson MG, levy D. Is pulse pressure
more important than systolic blood pressure in predicting coronary heart
- Choice of drug according to concomitant diseases disease event. Circulation 1999;100:354-60.
and other duugs.
4. Dalal PM. Hypertension – A report on community survey for casual hy-
- Ordinarily ca- channel blockers and diuretcs are pertension in old Bombay. Ed H Jhala Bombay Sir HN Hospital 1980.
1 line of choice. 5. Reaven GM. Insulin resistance, hyper-insulinemia and hyper-triglyceridemia
st
in the etiology clinical course of hypertension. Am J Med 1991;90:7S-12S.

GCDC 2017