JNC 8 Hypertension Guideline Algorithm

Initial Drugs of Choice for Hypertension

Adult aged ≥ 18 years with HTN  
• ACE inhibitor (ACEI)
Implement lifestyle modifications
• Angiotensin receptor blocker (ARB)
Set BP goal, initiate BP-lowering medication based on algorithm
• Thiazide diuretic
General Population • Calcium channel blocker (CCB)
(no diabetes or CKD) Diabetes or CKD present

Strategy Description
Age ≥ 60 years  Age < 60 years All Ages All Ages and Races Start one drug, titrate to maximum
A
Diabetes present CKD present with or dose, and then add a second drug.
No CKD without diabetes
BP Goal BP Goal B Start one drug, then add a second
< 150/90 < 140/90 drug before achieving max dose of
BP Goal BP Goal first
< 140/90 < 140/90
C Begin 2 drugs at same time,
ti me, as
separate pills or combination pill.
Initiate ACEI or ARB, Initial combination therapy is
Nonblack Black alone or combo recommended if BP is greater than
w/another class 20/10mm Hg above goal
Initiate thiazide, ACEI, ARB, Initiate thiazide or CCB,
or CCB, alone or in combo alone or combo
Lifestyle changes:
Yes
At blood pressure goal? • Smoking Cessation
• Control blood glucose and lipids
No
• Diet
Reinforce lifestyle and adherence Eat healthy (i.e., DASH diet)

Titrate medications to maximum doses or consider

consider adding another medication (ACEI, ARB, CCB, Thiazide) Moderate alcohol consumption
Reduce sodium intake to no
Yes more than 2,400 mg/day
At blood pressure goal?
• Physical activity
No
Moderate-to-vigorous activity
Reinforce lifestyle and adherence 3-4 days a week averaging 40
Add a medication class not already selected (i.e. beta blocker, aldosterone antagonist, others) and titrate
titr ate min per session.
above medications to max (see back of card)

Yes
At blood pressure goal? Continue tx and monitoring
No
Reference: James PA, Ortiz E, et al. 2014 evidence-based guideline for the management
Reinforce lifestyle and adherence of high blood pressure in adults: (JNC8). JAMA. 2014 Feb 5;311(5):507-20
Titrate meds to maximum doses, add another med and/or refer to hypertension specialist
Card developed by Cole Glenn, Pharm.D. & James L Taylor, Pharm.D.
 Compelling Indications
Hypertension Treatment
Indication Treatment Choice
Heart Failure ACEI/ARB + BB + diuretic + spironolactone

Post –MI/Clinical CAD ACEI/ARB AND BB

Beta-1 Selective Beta-blockers – possibly safer in patients
CAD ACEI, BB, diuretic, CCB with COPD, asthma, diabetes, and peripheral vascular
Diabetes ACEI/ARB, CCB, diuretic disease:
 metoprolol
•

CKD ACEI/ARB  bisoprolol

•

Recurrent stroke prevention ACEI, diuretic  betaxolol

•

 acebutolol
•

Pregnancy labetolol (first line), nifedipine, methyldopa

Drug Class Agents of Choice Comments

Diuretics HCTZ 12.5-50mg, chlorthalidone 12.5-25mg, indapamide 1.25-2.5mg Monitor for hypokalemia
triamterene 100mg Most SE are metabolic in nature
K+ sparing  – spironolactone 25-50mg, amiloride 5-10mg, triamterene Most effective when combined w/ ACEI
100mg Stronger clinical evidence w/chlorthalidone
Spironolactone - gynecomastia and hyperkalemia
furosemide 20-80mg twice daily, torsemide 10-40mg Loop diuretics may be needed when GFR <40mL/min
ACEI/ARB  ACEI: lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril 5- SE: Cough (ACEI only), angioedema (more with ACEI),
10mg, trandolapril 2-8mg hyperkalemia
 ARB: candesartan 8-32mg, valsartan 80-320mg, losartan 50-100mg, Losartan lowers uric acid levels; candesartan may
olmesartan 20-40mg, telmisartan 20-80mg prevent migraine headaches
Beta-Blockers metoprolol succinate 50-100mg and tartrate 50-100mg twice daily, Not first line agents  – reserve for post-MI/CHF
nebivolol 5-10mg, propranolol 40-120mg twice daily, carvedilol 6.25-25mg Cause fatigue and decreased heart rate
twice daily, bisoprolol 5-10mg, labetalol 100-300mg twice daily, Adversely affect glucose; mask hypoglycemic awareness
Calcium channel Dihydropyridines: amlodipine 5-10mg, nifedipine ER 30-90mg, Cause edema; dihydropyridines may be safely combined
blockers Non-dihydropyridines: diltiazem ER 180-360 mg, verapamil 80-120mg 3 w/ B-blocker
times daily or ER 240-480mg Non-dihydropyridines reduce heart rate and proteinuria
Vasodilators hydralazine 25-100mg twice daily, minoxidil 5-10mg Hydralazine and minoxidil may cause reflex tachycardia
and fluid retention – usually require diuretic + B-blocker

terazosin 1-5mg, doxazosin 1-4mg given at bedtime Alpha-blockers may cause orthostatic hypotension
Centrally-acting clonidine 0.1-0.2mg twice daily, methyldopa 250-500mg twice daily Clonidine available in weekly patch formulation for
Agents resistant hypertension
guanfacine 1-3mg