High blood pressure is a very common condition affecting a large number of men and women in England. Treatment of high blood pressure will depend on personal circumstances, for example, age, ethnicity of the patient and existence of other medical conditions they may have. In this post, I reviewed the most common medicines for blood pressure. The list of medicines is based on prescribing statistics in England (OpenPrescribing.net, 2022).
Table of Contents
What is high blood pressure? (video)
How is blood pressure treated?
Three factors affect the initial choice of antihypertensive medication:
- Age (is patient under or over 55 years of age)
- Presence of diabetes
- Family origin (is patient Black African or African–Caribbean family origin)
Treatment of high blood pressure is managed in a stepwise manner. In step 1, The National Institute for Health and Care Excellence (NICE) recommends the following treatment:
- Use of ACE inhibitor (like ramipril) or angiotensin II receptor blockers, ARB (like candesartan or losartan) in patients of any age who have diabetes or diabetic patients who are Black African or African–Caribbean family origin (any age)
- The above classes of drugs can also be offered to patients under 55 years of age but who are not of Black African or African–Caribbean family origin
- If ACE inhibitor is not tolerated patients can be offered, ARB
Calcium-channel blockers are recommended at step 1 to patients who are aged over 55 and do not have diabetes or to patients of any age who are of Black African or African–Caribbean family origin, but do not have diabetes:
If calcium channel blocker is not tolerated a thiazide-like diuretic (like indapamide) can be offered
Step 2 of hypertension treatment combines the use of two drugs, for example, ACE inhibitor or ARB with calcium channel blocker or ACE inhibitor or ARB.
Hypertension is not controlled with a calcium channel blocker, patients can be offered an ACE inhibitor, an ARB or a thiazide-like diuretic.
The most common medicines for blood pressure: by type of drug
High blood pressure can be treated with a number of drugs from different classes. British National Formulary (BNF) lists the following classes of antihypertensive drugs:
- Vasodilator antihypertensive drugs
- Centrally-acting antihypertensive drugs
- Adrenergic neurone blocking drugs
- Alpha-adrenoceptor blocking drugs
- Renin-angiotensin system drugs (ACE-inhibitors) and
- Other adrenergic neurone blocking drugs
In addition to the above groups, calcium channel blockers and diuretics (particularly thiazide diuretics) are also used in the treatment of hypertension. Calcium channel blockers are also used in the treatment of angina, whereas diuretics in oedema (excess of water) hence a different classification to antihypertensive drugs.
The table below lists the most common medicines for high blood pressure (group of drugs) from the above classification according to their prescribing popularity.
| Rank | Drug class |
Prescriptions issued in the last 12 months* |
Examples of drugs |
| 1 | Renin-angiotensin system drugs (including ACE inhibitors and ARB**) |
65,701,574 |
Candesartan, Lisinopril, Losartan, Ramipril |
| 2 | Calcium channel blockers |
44,292,265 |
Amlodipine, Nifedipine, Felodipine |
| 3 | Thiazides and related diuretics |
12,502,274 |
Bendroflumethiazide, Indapamide |
| 4 | Alpha-adrenoceptor blocking drugs |
6,783,250 |
Doxazosin, Prazosin, Terazosin |
| 5 | Centrally-acting antihypertensive drugs |
463,093 |
Clonidine, Methyldopa, Moxonidine |
| 6 | Vasodilator antihypertensive drugs |
212,252 |
Hydralazine hydrochloride, minoxidil |
| 7 | Adrenergic neurone blocking drugs |
0 |
Guanethidine monosulfate |
| 8 | Other adrenergic neurone blocking drugs |
0 |
Ketanserin |
*number of prescriptions issued by NHS England Feb ’21—Jan ’22 (OpenPrescribing.net, 2022), ** ARB = angiotensin II receptor blockers
Renin-angiotensin system drugs (including ACE inhibitors) are the most common class of medicines prescribed for the treatment of hypertension with over 65 mln prescriptions issued in the last 12 months. Calcium channel blockers are slightly less popular with over 44 mln prescriptions issued in the same period. Thiazides and related diuretics close the top 3 with 12.5 mln prescriptions issued.
Centrally-acting antihypertensive drugs and vasodilator antihypertensive drugs are much less popular with an almost insignificant number of prescriptions issued when looking at the overall number of prescriptions issued for the treatment of hypertension.
Why renin-angiotensin system drugs are the most common medicines for blood pressure?
Without a detailed analysis and just by looking at the guidelines it is not clear why renin-angiotensin system drugs are the most common medicines for blood pressure. Since the prevalence of high blood pressure increases with age one would expect calcium channel blockers to be the most popular class of antihypertensive drugs. The popularity of renin-angiotensin system drugs may partly be explained by the presence of diabetes in patients over 55, with the risk of diabetes increasing with age. To recap, renin-angiotensin system drugs like ACE inhibitors would be preferred in patients with diabetes.
The most common medicines for blood pressure: individual drug classification
The table below lists the top 15 most common medicines for blood pressure prescribed in England. The table lists drug classification and the number of prescriptions issued in 12 month period (Feb ’21 —Jan ’22). I included also the total cost for each drug which applies to the same period. The last column represents the price of drugs per prescription issued.
Cost-effectiveness is a big part of prescribing and as we can see from the table more expensive drugs are less prescribed, since the cheaper alternative, very often within the same drug class exist.
| Rank | Drug class | Drug | Prescriptions issued | Cost | Cost per issue |
| 1 | CCB | Amlodipine | 32,719,247 | 38,564,363 | £1.18 |
| 2 | ACE inhibitor | Ramipril | 30,320,180 | 43,526,682 | £1.44 |
| 3 | ARB | Losartan | 10,683,796 | 23,639,395 | £2.21 |
| 4 | ACE inhibitor | Lisinopril | 8,076,952 | 11,252,121 | £1.39 |
| 5 | Diuretics | Bendroflumethiazide | 7,383,376 | 7,609,082 | £1.03 |
| 6 | ARB | Candesartan | 7,263,580 | 19,580,488 | £2.70 |
| 7 | Diuretic | Indapamide | 5,082,593 | 14,786,172 | £2.91 |
| 8 | CCB | Felodipine | 3,394,828 | 20,168,617 | £5.94 |
| 9 | CCB | Lercanidipine | 2,958,363 | 10,393,593 | £3.51 |
| 10 | ACE inhibitor | Enalapril | 1,355,198 | 14,726,313 | £10.87 |
| 11 | CCB | Nifedipine | 513,017 | 7,556,169 | £14.73 |
| 12 | ARB | Olmesartan | 386,213 | 3,936,667 | £10.19 |
| 13 | ARB | Telmisartan | 306,033 | 998,158 | £3.26 |
| 14 | Beta-blocker | Labetalol | 109,805 | 973,521 | £8.87 |
| 15 | ACE inhibitor | Captopril | 55,218 | 1,487,759 | £26.94 |
1. Amlodipine – the most common medicine for blood pressure
Amlodipine is the most commonly prescribed medication for blood pressure in England. Amlodipine is classified as a calcium channel blocker. It comes as no surprise since CCBs are recommended as the first-line treatment for adults (without diabetes) who are over 55 years of age. The low cost of the drug also drives its popularity. Amlodipine comes in form of tablets and as an oral solution.
Amlodipine tablets are available in the following strengths:
- 2.5mg tablets, the newest addition to the range, not commonly prescribed
- 5mg tablets
- 10mg tablets
Amlodipine: common and very common side effects
Patients taking amlodipine may experience the following side effects (BNF, 2022):
- dizziness
- drowsiness
- flushing
- headache
- nausea
- palpitations
- peripheral oedema
- skin reactions
- tachycardia
- vomiting
- abdominal pain
Peripheral oedema, very often represented by swelling in the ankles, feet or legs is a common reason for the discontinuation of the treatment with amlodipine.
In addition to high blood pressure treatment (hypertension), amlodipine can also be used as prophylaxis for angina (chest pains caused by the disturbed blood supply to the heart).
2. Ramipril
The second most common high blood pressure medication is ramipril. Ramipril is classified as an ACE inhibitor (ACE). ACEs are recommended for patients who are under 55 years of age (not Black African or African–Caribbean family origin) or of any age who have diabetes including Black African or African–Caribbean patients. The recommended use of ramipril for the treatment of high blood pressure in diabetes adds to the popularity of ramipril and ACEs overall.
Additionally, ACE inhibitors are used in the treatment of other conditions:
- Symptomatic heart failure
- Prophylaxis after myocardial infarction (heart attack) in patients with heart failure
- Prevention of cardiovascular events such as heart attack
- Nephropathy (deterioration of kidney function)
Ramipril: formulations
Ramipril comes in form of tablets, capsules and oral solution. Tablets and capsules come with a range of strengths:
- 1.25mg tablet or capsule
- 2.5mg tablet or capsule
- 5mg tablet or capsule
- 10mg tablet or capsule
Ramipril: common and very common side effects
Ramipril is associated with several common and very common side effects, most of them apply to the whole class of ACE inhibitors. Please refer to the products information leaflet to see all side effects, some include:
- Constipation (see Laxido alternative drugs)
- Cough
- Diarrhoea
- Dry mouth
- Headache
- Tiredness
- Nausea
- Vomiting
- Skin reactions
- Alopecia (hair loss)
Patients are usually warned about the possibility of a cough. The cough is usually persistent and does not go away. If this side effect is experienced, patients are usually switched to a different antihypertensive medication.
3. Losartan
Slightly less popular, but still with high overall prescribing volume is losartan. Losartan is the first drug on the list which is classified as an angiotensin II receptor blocker (ARB). ARBs have the same recommended use as ACE inhibitors. Very often, ARBs like losartan are prescribed when ACE inhibitor is not tolerated.
In addition to the treatment of high blood pressure losartan can also be used in (BNF, 2022):
- Diabetic nephropathy (kidney damage) in type 2 diabetes
- Chronic heart failure when ACE inhibitors are unsuitable or contra-indicated
Losartan: drug form
Losartan comes only in the form of tablets with the following strengths:
- 12.5mg tablet
- 25mg tablet
- 50mg tablet
- 100mg tablet
Losartan: common and very common side effects
The whole class of ARB is associated with a number of common side effects (ibid), however, BNF and products information leaflet lists less common side effects associated with losartan:
- Dizziness
- Vertigo
- Higher than normal level of potassium
4. Lisinopril
The second ACE inhibitor on the list of most common medicines for blood pressure, lisinopril is four times less prescribed than ramipril. Lisinopril has some additional uses, apart from the treatment of high blood pressure, which are different o ramipril. The side effect profile is similar to ramipril, see paragraph reviewing ramipril.
Lisinopril: forms and strengths
Lisinopril comes in form of tablets and also as an oral solution. Tablets, which are the most common form prescribed include:
- 2.5mg tablets
- 5mg tablets
- 10mg tablets
- 20mg tablets
5. Bendroflumethiazide
Bendroflumethiazide is the first diuretic on the list, commonly known as a ‘water tablet’. Although bendroflumethiazide is ranked mongs the most common medications for blood pressure its prescribing popularity needs to be looked at with caution. Although licensed for high blood pressure, bendroflumethiazide is not a first-choice diuretic, which is recommended for the treatment of high blood pressure. Its popularity is mostly driven by its additional licensed use as a medication for the treatment of oedema.
Bendroflumethiazide: drug form and strength availability
Bendroflumethiazide is only available in the form of tablets. 2.5mg and 5mg tablets are available, with 2.5mg tablets being the most popular.
Bendroflumethiazide: side effects
There are no specific common side effects listed for bendroflumethiazide, however, some coon side effects apply to the whole class of diuretics (BNF, 2022):
- Constipation (See Movicol alternative drugs)
- Diarrhoea
- Dizziness
- Dry mouth
- Erectile disfunction
- Fatigue
- Headache
- Nausea
6. Candesartan
Candesartan is second on the list of angiotensin II receptor blockers, although less popular than losartan. In addition to hypertension, candesartan can also be used in heart failure and to prevent migraines. Candesartan comes only in form of tablets:
- 2mg tablets
- 4mg tablets
- 8mg tablets
- 16mg tablets and
- 32mg tablets
For side effects, please review the information included with the review of losartan.
7. Indapamide
The second diuretic on the list, indapamide is less commonly used than bendroflumethiazide, however as I discussed previously, cation should be taken when looking at prescribing statistics for bendroflumethiazide. When diuretics are considered for the treatment of high blood pressure, NICE recommends indapamide in preference to bendroflumethiazide (NICE, 2022).
Indapamide is only used for the treatment of high blood pressure, in contrast to bendroflumethiazide, which has additional licensed uses.
Indapamide comes only in a form of tablets: 2.5mg tablets or 1.5mg tablets in a modified release formulation are available.
The rest of the list includes different drugs from all classes of medicines for blood pressure reviewed already except for labetalol. Labetalol is a beta-blocker. Beta-blockers used to be prescribed for the treatment of high blood pressure in the past. Labetalol, however, is an exception as this drug is licensed and used for the treatment of high blood pressure in pregnancy. The rest of the drugs on the list of common medicines for high blood pressure:
8. Felodipine
9. Lercanidipine
10. Enalapril
11. Nifedipine
12. Olmesartan
13. Telmisartan
14. Labetalol
15. Captopril
I have not reviewed in detail each drug due to its lesser popularity and due to each drug belonging to a class of high blood pressure medicines previously reviewed in this post.
References:
BNF (2022). Drugs: Amlodipine. Available at: https://bnf.nice.org.uk/drug/amlodipine.html Accessed on 10/04/2022
BNF (2022). Drugs: Losartan. Available at: https://bnf.nice.org.uk/drug/losartan-potassium.html Accessed on 10/04/2022
BNF (2022). Drugs: Bendroflumethiazide. Available at: https://bnf.nice.org.uk/drug/bendroflumethiazide.html Accessed on 10/04/2022
NICE (2022). Hypertension in adults: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng136 Accessed on 10/04/2022
OpenPrescribing.net (2022). Drug analysis. Available at: https://openprescribing.net/ Accessed on 10/04/2022
