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HelixTalk Episode #65 - Advanced hypertension ninja skills with some of the oldest BP meds

Date posted: August 15, 2017, 6:00 am

In this episode, we discuss three "older" antihypertensives that are not preferred first-line therapies: clonidine, methyldopa, and minoxidil.  We outline why these agents are not first-line therapies and review their pharmacology and adverse effect profiles.


Key Concepts

  1. The first-line therapies for hypertension (thiazides, calcium channel blockers, ACE inhibitors, and ARBs) are preferred options because we have good comparative data investigating long-term clinical outcomes for these drugs.
  2. Clonidine can cause sedation, dry mouth, impotence, and bradycardia.  It is available as an oral tablet (typically taken twice a day) or a patch (replaced once weekly).  Importantly, a patient may have rebound tachycardia, hypertension, and other withdrawal symptoms if clonidine is taken chronically and suddenly stopped.
  3. Methyldopa is one of three preferred antihypertensives for pregnant women.  Nifedipine XL and labetalol are likely equally effective and safe, but may have a more favorable adverse effect profile for the mother.
  4. Minoxidil has a number of serious adverse effects as outlined in its boxed warnings, including the risk of tachycardia (causing angina), edema (requiring a concomitant loop diuretic), and pericardial effusion possibly resulting in tamponade (a medical emergency).


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  • James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. doi: 10.1001/jama.2013.284427.
  • Slim HB, Black HR, Thompson PD. Older blood pressure medications-do they still have a place? Am J Cardiol. 2011 Jul 15;108(2):308-16.
  • McComb MN, Chao JY, Ng TM. Direct Vasodilators and Sympatholytic Agents. J Cardiovasc Pharmacol Ther. 2016 Jan;21(1):3-19.