A step-wise approach to treatment is normally adopted with antihypertensive medicines. Before moving onto the next step, the medicine(s) should be reviewed to ensure concordance and that the medicine is at optimal or best tolerated doses.

Step 1: First-line treatments

Individuals under 55 years (who are not pregnant) are prescribed:

• Angiotensin-converting enzyme (ACE) inhibitor or, where not tolerated due to side effects (e.g. cough), a low-cost angiotensin II receptor blocker (ARB)
• An ACE inhibitor must not be combined with an ARB.

Individuals aged over 55 years, and black people of African or Caribbean origin of any age, are prescribed:

• A calcium-channel blocker (CCB) or where not suitable, for example due to oedema or heart failure, a thiazide-like diuretic, such as chlortalidone or indapamide.

Step 2: Second-line treatments

• A CCB and the addition of either an ACE inhibitor or an ARB. (For black people of African or Caribbean origin, an ARB should be used in preference to an ACE inhibitor)
• If a CCB is not suitable because of oedema, intolerance or heart failure, a thiazide-like diuretic should be used.

Step 3: Third-line treatments

• Triple therapy of drugs including a combination of an ACE inhibitor or angiotensin II receptor blocker, a calciumchannel blocker and a thiazidelike diuretic.

Step 4: Fourth-line treatments

One of the following medicines are added to treat resistant hypertension:

• Low-dose spironolactone
• Higher-dose thiazide-like diuretic
• Alpha blocker
• Beta-blocker if further diuretic therapy is contraindicated, not tolerated, or ineffective.