Blood Pressure Medications
Classes, side effects, and what to teach
| Class | Examples | Key side effects and nursing points |
|---|---|---|
| ACE inhibitors (-pril) | lisinopril, enalapril, ramipril, captopril | Dry cough; angioedema (stop, protect airway; can happen any time); ↑ K⁺; first-dose hypotension; small creatinine rise is expected. Teratogenic. Avoid potassium supplements and salt substitutes. |
| ARBs (-sartan) | losartan, valsartan, olmesartan | Like ACE inhibitors but cough is rare. Never combine an ACE inhibitor + ARB. Teratogenic. |
| ARNI | sacubitril/valsartan | For HFrEF. 36-hour gap after stopping an ACE inhibitor. |
| Beta blockers (-olol) | Cardioselective (β1): metoprolol, atenolol, bisoprolol. Non-selective: propranolol, nadolol; carvedilol and labetalol also block α1 | Bradycardia, hypotension, fatigue; bronchospasm (non-selective, caution in asthma); masks hypoglycemia (tachycardia, tremor; sweating still occurs). Don't stop abruptly (rebound tachycardia, angina). Hold per parameters (often HR <60, SBP <90–100). |
| Dihydropyridine CCBs (-dipine) | amlodipine, nifedipine | Ankle edema, flushing, headache, reflex tachycardia, gum overgrowth. Immediate-release nifedipine is not for chronic BP control. |
| Non-dihydropyridine CCBs | diltiazem, verapamil | Slow the heart: bradycardia, heart block; constipation (verapamil). Avoid in HFrEF. Grapefruit interaction. |
| Thiazide diuretics | chlorthalidone, hydrochlorothiazide | ↓ K⁺, ↓ Na⁺, ↑ Ca²⁺, ↑ glucose, ↑ uric acid (gout); see Diuretics. |
| Alpha-1 blockers (-osin) | doxazosin, prazosin, terazosin | First-dose orthostatic hypotension: take at bedtime. Also used for BPH (tamsulosin). |
| Central alpha-2 agonists | clonidine, methyldopa | Drowsiness, dry mouth, bradycardia. Clonidine: severe rebound hypertension if stopped suddenly. Methyldopa is used in pregnancy. |
| Direct vasodilators | hydralazine, minoxidil, nitroprusside (IV) | Reflex tachycardia, fluid retention. Hydralazine: lupus-like syndrome. Nitroprusside: ICU only, protect from light, cyanide toxicity. |
Teaching for every BP drug
- Change position slowly; sit before standing; dangle legs.
- Don't stop suddenly (especially beta blockers, clonidine).
- Keep a home BP log; report dizziness or fainting.
- Avoid NSAIDs and decongestants (raise BP; NSAIDs harm kidneys with ACEi/ARB + diuretic).
- Limit alcohol and salt; take as prescribed even when feeling well.
Special situations
- Pregnancy: labetalol, extended-release nifedipine, methyldopa. No ACE inhibitors, ARBs, ARNI.
- Diabetes or CKD with protein in urine: ACE inhibitor or ARB preferred.
- Asthma: avoid non-selective beta blockers.
- Gout: thiazides can trigger attacks; losartan lowers uric acid.
- Angioedema history: no ACE inhibitors or ARNI.
Memory hook
ACE inhibitors cause a "hacking cough" and keep K⁺ (potassium) in: "ACE = Angioedema, Cough, Elevated potassium."