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Evidence for Chlorthalidone-Amlodipine-Spironolactone Use to Achieve Recommended BP Targets

Jackson Wright MD PhD

The Hypertension Change Package Algorithm covers a widely acceptable and effective algorithm using inexpensive combination therapy. This algorithm was recommended in Systolic Blood Pressure Intervention Trial (SPRINT), with chlorthalidone, the preferred thiazide-like diuretic, especially for African-American patients.  Compared to hydrochlorothiazide (HCTZ), chlorthalidone is twice as potent in lowering blood pressure, has a more gradual onset of diuretic action, and has larger evidence base documenting cardiovascular disease (CVD) reduction. Chlorthalidone also increases duration of action for lowering blood pressure.

Amlodipine, like chlorthalidone, has a substantial half-life (40-60 hrs) and consequently more tolerant of missed doses. It has a significant evidence base demonstrating reduction of CVD events, and thus can be prescribed as an initial or add-on agent. It is effective regardless of age, race, or renal function. In patients with kidney dysfunction, it should be combined with an Angiotensin-converting-enzyme inhibitors (ACEi) or Angiotensin II Receptor Blockers (ARB). 

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