Optimizing management of hypertension with combination therapy: considerations for the nurse practitioner

Hypertension is an important contributor to the risk of cardiovascular disease and death, yet success in achieving blood pressure (BP) control has been limited. Most patients will require 2 or more medications to control their BP. Nurse practitioners play a vital role in treating patients with hypertension and can help overcome barriers to reaching BP goals. Measures to improve therapeutic adherence include educating the patient and simplifying the medication regimen. Use of single-pill combination therapy, which reduces the pill burden, can contribute to improved medication persistence and compliance. Rational combination therapy combines medications with complementary mechanisms of action, such as a calcium channel blocker (CCB) and a renin-angiotensin-aldosterone system (RAAS) inhibitor; it is often more efficacious than monotherapy and allows the use of lower doses of the individual components, which usually results in improved tolerability. Current guidelines support the first-line use of combination therapy in many patients. Initiating therapy with a RAAS inhibitor-based combination can reduce BP and cardiovascular risk and may be more effective for some patients than traditional combinations such as a beta-blocker with a diuretic. Adverse events associated with any medication can compromise its therapeutic usefulness. Peripheral edema is a common and dose-dependent adverse event seen with dihydropyridine CCBs, which can cause marked patient distress, reduce adherence to therapy, and result in dose reduction or even discontinuation of therapy. In most cases, CCB-induced peripheral edema can be managed successfully, and CCB therapy need not be abandoned. Management strategies include nonpharmacologic and pharmacologic measures. Several clinical trials have shown a lower incidence of peripheral edema in patients receiving combination therapy with a CCB and a RAAS blocker compared with CCB monotherapy.