Introduction.
Hypertension is one of the most common lifestyle-related diseases, affecting one out of every three adults in Japan. While lifestyle modification through diet and exercise is fundamental, in many cases drug therapy is necessary.
The Japanese Society of Hypertension's "Guidelines for the Treatment of Hypertension 2025" clarifies the steps in drug therapy, combination therapy, and the position of newly introduced drugs (such as ARNI). This article organizes the types of medications and how to proceed with treatment that patients should be aware of.
1. basic policy of hypertension treatment
Guideline 2025 is based on lifestyle modification plus stepwise drug treatment.
- Monotherapy in the early stages
- If ineffective, use 2-drug combination
- If that is not sufficient, introduce three or more drugs or new drugs
This "step method" is clearly indicated to reach the target blood pressure (clinic: <130/80 mmHg, home: <125/75 mmHg) earlier.
2. major types of hypertension medications
(1) Calcium channel blocker (CCB)
- Dilation of blood vessels and lowering of blood pressure.
- One of the most used drugs by the Japanese
- Facial hot flashes and swelling are common side effects.
(2) Renin-angiotensin system inhibitors (ARBs and ACE inhibitors)
- Suppresses hormones that constrict blood vessels
- Nephroprotective, useful for patients with diabetes and proteinuria
- Beware of cough (ACE inhibitors) and hyperkalemia
(3) Diuretics
- Discharges excess salt and water into the urine
- Particularly useful for the elderly and in cases of heart failure complications
- Beware of hypokalemia and elevated uric acid.
(4) Beta-blockers
- Reduces heart rate and heart strain
- Useful for patients with angina pectoris or post-myocardial infarction
- In bronchial asthma and bradycardia注意
Combination Therapy - Early on, two drugs are used together.
Guideline 2025 recommends the use of a two-drug combination as soon as possible if the effect of a single agent is inadequate.
Commonly used combinations are:
- CCB + ARB
- ARB + diuretics
- CCB + diuretics
Combining several drugs in small doses ensures antihypertensive effects while reducing side effects.
4. treatment of treatment-resistant hypertension
When blood pressure does not decrease even with lifestyle modification and a three-drug combination, it is called "treatment-resistant hypertension". Here is an option:
(1) MRA (mineralocorticoid receptor antagonist)
- Spironolactone, eplerenone, etc.
- Blocks salt retaining hormone (aldosterone)
- Especially effective in primary aldosteronism and resistant hypertension
(2) ARNI (angiotensin receptor neprilysin inhibitor)
- Sacubitril/valsartan
- Two actions: RAAS inhibition + diuretic peptide potentiation
- Originally a drug for heart failure, but JSH 2025 also describes its application for hypertension
- Consideration for treatment-resistant cases and hypertension with cardiac and renal complications
However, ARNI and MRA areNot to be used as a first choice for all patients, but a "second step or later option" to be introduced after a combination of lifestyle modification and standard medicationsThis is the position of the company.
5. side effects and precautions
- Low blood pressure and dizziness: especially when taking multiple medications
- Renal dysfunction and electrolyte abnormalities: monitoring is especially necessary with ARBs, ACE inhibitors, and MRAs
- Elderly: Target blood pressure is individually adjusted because excessive blood pressure reduction may also contribute to falls and dementia risk
6. efforts at the Ikejiri-Ohashi Sera Clinic
In accordance with our guidelines:
- Thoroughly improve lifestyle first, then introduce drugs when necessary.
- Medication is administered in a step-by-step approach, always checking for side effects and complication risks.
- MRA and ARNI are also options for resistant hypertension, with careful follow-up of renal and cardiac function
- Comprehensive evaluation, including home blood pressure records and fundus examination, is provided to ensure that the patient can continue treatment with peace of mind.
summary
- The basis of hypertension treatment is lifestyle modification + drug therapy
- Medications are mainly CCBs, ARBs/ACEs, diuretics, and beta-blockers
- Early 2-drug combination, to 3-drugs or MRA and ARNI if needed
- ARNI appears as an "additional option in treatment-resistant or complicated cases
- Individualized treatment is important, taking into account side effects and complications.
References
- The Japan Society of Hypertension. Guidelines for the Treatment of Hypertension 2025.
- Onoyuri Clinic. "Commentary on the 2025 Guidelines for the Treatment of Hypertension" (onoyuri-clinic.jp)
- ACC Expert Consensus on ARNI use in Hypertension (acc.org)
- Whelton PK, et al. JNC7 report. JAMA. 2003.
Symptoms and Causes of Hypertension