Doctors are usually a lot more sceptical about population studies than reporters, which is why I wrote questioning the glaring headlines about a study which claimed a certain blood pressure medicine (ACE 2 medicines) increased the risk of cancer.

The study was a study lumping together a lot of different studies which may or may not be as strict with their criteria or may include patients who lie about their dietary or other bad habits. And since docs use “ACE inhibitors” more in diabetics, and diabetics have a higher risk for some cancers, one wonder if this (and the lack of data on smokers) might be behind the statistical increase in cancer.

So what should you do? Panic and stop your blood pressure medicine?

No. The risk of heart attack or stroke is much much higher than that small statistical “blip” in the data wondering about cancer increase.

But are you on the best medicine? That depends on you.

We docs usually start with one medicine, and if it doesn’t work, add a second (or third).

A recent study suggested the old thiazide diuretics, (AKA “water pills” e.g HCTZ, Dyazide) which are cheap and have been around for 50 years, should be the first medicine tried.

Docs got away from using these for awhile: For edema (water retention) the newer diuretics worked better (e.g. Lasix, furosemide), and we saw side effects when we used thiazides in high doses (mainly low potassium, but also impotence and rare allergy or platelet problems).

But now studies show you don’t need the large doses to lower blood pressure, so they are staging a come back.

What to use next? Calcium channel blockers (e.g. Norvasc, procardia, nefedipine)? They work by opening up the blood vessels. We often start them first, because they have the least side effects (swollen legs with some, and constipation, and they can increase the work of the heart, which is mainly a problem for those with severe heart disease). But they only last for one day, so if your patient misses a dose, his blood pressure will soar. (newer versions and extended release tablets have cut this problem).

Then we have the beta blockers (eg. Inderal, metoprolol, atenolol). Essentially they block adrenalin, the hormone you put out when you are upset or angry. The bad news: They don’t really prevent “end stage” damage from blood pressure. But if you are a person whose blood pressure soars off the top of the chart when you are upset, they might be the one for you, especially if you have heart disease.

Their main problem: Tiredness, which is dose related.

Then we come to the “Ace inhibitors” which work via the kidneys (renin/angiotensin system). Their problems are mainly in those who have bad kidneys, but in Diabetics they actually slow down the damage to the kidney, so they are the drug of choice.

ACE 1 (e.g. lisinopril, enalapril) however have a nasty cough/tickle in the throat that causes ten to twenty percent of folks from using it. ACE2 (losartan, irbasartan) medicine are then used, and their main problem is they are more expensive, but some docs use these as “first line” drugs because of this side effect in the ACE 1 medications.

They can’t be used if you have high blood pressure from renal artery stenosis (rare) or are pregnant.

Which brings us to the other medicines. The oldies but goodies, which we docs mainly use in very severe cases of blood pressure, or for pregnant women who have high blood pressure.

We might use an alpha blocker in a man with a large prostate, for example, because it improves both problems at once. Clonidine comes in patches and we can use them for a forgetful patient with very bad blood pressure, even though it can make people sleepy.

The older “centrally active” medicines (e.g. aldomet, methyldopa), that work in the brain, also cause sedation, so we usually only use them in cases where nothing else works. We also use aldomet in pregnant women with severe high blood pressure because it is the safest one for the baby.

Finally, there is diet and exercize. Losing weight and keeping fit help, as does a low salt diet.

The bad news is that once you have high blood pressure, a low salt diet has only a small effect in lowering the blood pressure.

So what do you do?

Take your pills every day, read the side effects, but remember that every medicine has side effects.

But you have to balance the usually mild side effects against the severe problems caused by not treating high blood pressure, such as strokes, heart attacks, and kidney failure.

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Nancy Reyes is a retired physician living in the rural Philippines.

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