Initial Treatment of Adult Patients With Essential Hypertension

The stepped-care approach to the treatment of hypertension suggests the use of a diuretic or, in some cases, a beta blocker as initial monotherapy. If either of these agents proves to be ineffective, the other can be tried as monotherapy. Stepped-care suggests the use of different classes of drugs that affect different mechanisms related to hypertension at various stages of treatment. Although empiric, the concept makes good physiologic sense. Results of its use in major clinical trials, as well as an extensive private practice experience, suggest that in a large majority of patients, hypertensive can be controlled with relatively little expense, few titration problems and a high rate of adherence. Advocates of individualization of care, or sequential monotherapy, base their suggestion on theory, but widespread use of this approach would make management more complex and more expensive, and would probably decrease adherence to long-term treatment. Stepped-care treatment allows for adequate individualization and a wide choice of drugs, and should continue to be employed unless data are obtained that demonstrate a better outcome with sequential monotherapy or other more complex approaches.