antihypertensive treatment NICE guidelines

stage 1

What is the Step 1 antihypertensive for people <55 years (not of Black African/Caribbean origin)?

ACE inhibitor (ACEI); if not tolerated (e.g. cough) → ARB.

What is the Step 1 antihypertensive for all individuals with Type 2 diabetes?

ACEI or ARB (any age, any ethnicity)

What is the Step 1 treatment for Black African or African–Caribbean origin (without diabetes)?

Calcium channel blocker (CCB); or ARB (prefer over ACEI).

What if a CCB is not suitable (e.g. causes oedema or patient has heart failure)?

Use a thiazide-like diuretic instead

Which thiazide is preferred according to NICE?

Thiazide-like diuretics (e.g. indapamide) preferred over conventional thiazides (bendroflumethiazide, hydrochlorothiazide).

Should patients stable on old thiazides be switched?

No — continue if BP is well controlled

stage 2

What should be added if patient is on an ACEI/ARB (Step 1)?

Add CCB or thiazide-like diuretic

What should be added if patient is on a CCB (Step 1)?

Add ACEI/ARB or thiazide-like diuretic

For Black African/Caribbean patients (no diabetes), what is preferred at Step 2?

Add ARB (not ACEI).

stage 3

What is the standard triple therapy at Step 3?

ACEI/ARB + CCB + thiazide-like diuretic.

stage 4 - resistant hypertension

What is added if BP uncontrolled on Step 3 and K⁺ ≤ 4.5 mmol/L?

Add low-dose spironolactone.
(Monitor Na⁺, K⁺, renal function within 1 month.)

What is added if K⁺ > 4.5 mmol/L?

Add an α-blocker or β-blocker.