NHS Hypertension Treatment: A Guide to the 4 NICE Medication Steps

NHS Hypertension Treatment: A Guide to the 4 NICE Medication Steps

This article explains how your age, ethnicity, and health profile determine which high blood pressure tablets you should be prescribed under UK guidelines.

The UK’s National Institute for Health and Care Excellence (NICE; which advises the NHS) provides a clear, stepwise algorithm for managing hypertension (high blood pressure).

This strategy is primarily determined by a your age, ethnicity, and the presence of Type 2 Diabetes.

Most patients can be managed by their GP. Resistant cases should be referred to a high blood pressure specialist (see below).

The NICE Treatment Steps

Step 1: Choosing the First Drug

The choice depends on the patient’s profile:

• Type 2 Diabetes (any age/ethnicity): Start with an ACE inhibitor (e.g. Ramipril) or an ARB (e.g. Losartan).

• Aged < 55 and NOT of Black African or African-Caribbean family origin: Start with an ACE inhibitor or ARB.

• Aged ≥ 55 OR of Black African or African-Caribbean family origin (any age): Start with a Calcium-channel blocker (CCB) (e.g. Amlodipine).

Note: If a CCB is not tolerated, a Thiazide-like diuretic (e.g. Indapamide) is used instead.

Step 2: Dual Therapy

If BP remains uncontrolled (>140/90 mmHg in the clinic), a second drug is added:

• ACE-I or ARB + CCB

• ACE-I or ARB + Thiazide-like diuretic

• CCB + Thiazide-like diuretic

Step 3: Triple Therapy

If targets are still not met, triple therapy is required:

• ACE-I/ARB + CCB + Thiazide-like diuretic (e.g. Bendroflumethiazide)

Step 4: Resistant Hypertension

If BP is still high despite three drugs at optimal doses, the condition is “resistant.” In this situation, an underlying cause of high blood pressure is likely. This is called secondary hypertension.

• If Potassium is <4.5 mmol/l: Add low-dose Spironolactone.

• If Potassium is > 4.5 mmol/l: Add an Alpha-blocker (e.g. Doxazosin) or a Beta-blocker (e.g. Bisoprolol).

• Refer to local hospital high blood pressure clinic: These can be run by doctors that specialise in cardiology, diabetes and endocrinology or nephrology.

Where do other drugs fit?

While the first four steps cover most patients, other drugs have specific “niche” roles:

Note: NICE guidelines strictly advise never combining an ACE inhibitor with an ARB due to the risk of acute kidney injury (AKI).