Recommendation ID

Are there subgroups of people with hypertension who should start on dual therapy?

Any explanatory notes
(if applicable)

Why the committee made the recommendations
The committee reviewed the evidence for starting treatment for primary hypertension with a single antihypertensive medicine compared with starting with 2 antihypertensive medicines at once (dual therapy). Additionally, the committee reviewed the evidence on whether specific subgroups of people with hypertension might benefit from starting on dual therapy, for example people with type 2 diabetes, older people, or those of particular family origins.

Some limited evidence from a single study showed that initial dual therapy may reduce cardiovascular events in people with hypertension and type 2 diabetes, but the committee members were disappointed that more comprehensive data were not available. The committee discussed the benefits of optimising treatment for hypertension early and agreed that this can substantially improve quality of life. However, there was not enough evidence to determine confidently the benefits or harms of starting treatment with dual therapy. In response to the lack of available evidence, the committee developed a research recommendation to determine if particular subgroups would benefit from starting dual therapy, to inform future guidance.

In the absence of compelling new evidence on step 1 dual therapy, the committee agreed that the previous recommendations for step 1 treatment should be retained (with minor changes for clarity), because they were based on robust clinical and cost-effectiveness evidence. One exception to this was the 2006 recommendation for considering beta-blockers in certain groups of younger people. The committee discussed this recommendation and agreed that beta-blockers are rarely used as step 1 antihypertensive treatment in current practice and there is no established relationship between beta-blocker use in primary hypertension and a reduction in cardiovascular events. For these reasons, the committee decided that the recommendation should not be retained. The committee noted that this is consistent with most international guidelines.

This update of the guideline also updates and replaces the section on blood pressure management from NICE's guideline on type 2 diabetes in adults. That guideline recommended that adults with type 2 diabetes of any age should start on an angiotensin converting enzyme (ACE) inhibitor as step 1 treatment (except women with a possibility of becoming pregnant and people of black African or African–Caribbean family origin). The committee discussed the evidence for this and agreed that it was sufficient to support and retain this recommendation. The committee agreed it should be broadened to include the choice of an ACE inhibitor or an angiotensin-2 receptor blocker (ARB; also referred to as A-type drugs), because they are now cost equivalent, and the committee also agreed they are clinically equivalent.

For people of black African or African–Caribbean family origin with type 2 diabetes, the previous recommendation was to offer step 1 dual therapy with an ACE inhibitor and either a diuretic (D-type drug) or a calcium channel blocker (CCB; C-type drug). However, these recommendations were based on monotherapy studies and when the committee looked at this evidence alongside the new dual therapy evidence review, they concluded that it was insufficient to recommend starting dual therapy in any subgroup of people with type 2 diabetes. The committee noted that people with type 2 diabetes who are older or are of black African or African–Caribbean family origin may not achieve their target blood pressure on ACE inhibitor or ARB monotherapy and may need to start step 2 drug therapy in the short term.

How the recommendations might affect practice
Overall, the recommendations for step 1 treatment reflect current practice for people who do not have type 2 diabetes. For people of black African or African–Caribbean family origin who have type 2 diabetes, the recommendation to start antihypertensive monotherapy rather than dual therapy may result in an extra clinical appointment if the dose needs to be adjusted. However, it may also reduce potential harms from initial overtreatment of blood pressure.

Full details of the evidence and the committee's discussion are in evidence review E: step 1 treatment.

Source guidance details

Comes from guidance
Hypertension in adults: diagnosis and management
Date issued
August 2019

Other details

Is this a recommendation for the use of a technology only in the context of research? No  
Is it a recommendation that suggests collection of data or the establishment of a register?   No  
Last Reviewed 31/08/2019