How To Deal With Resistant Hypertension

Eli Ben-Yehuda

Written by Eli Ben-Yehuda

On October 12, 2019
What happens when you hit a high blood pressure plateau?

You’ve made lifestyle changes. You’re taking a diuretic and at least two other blood pressure medicines. But your blood pressure still isn’t budging. This is called resistant hypertension. Simply put, it means that your high blood pressure (HBP or hypertension) is hard to treat and may also have an underlying (secondary) cause.

Possible causes of resistant hypertension:

Resistant hypertension may have one or more other underlying medical conditions. In addition to treating resistant hypertension with medications, doctors typically investigate secondary causes (contributing factors), such as:

Abnormalities in the hormones that control blood pressure. The accumulation of artery-clogging plaque in blood vessels that nourish the kidneys, a condition called renal artery stenosis. Sleep problems, such as the breath-holding type of snoring known as obstructive sleep apnea. Obesity or heavy intake of alcohol or other substances that can interfere with blood pressure.

Monitoring and treatment of resistant hypertension:

Reining in blood pressure levels begins with the basics, such as understanding your pressure patterns. Sometimes that means wearing a pager-sized automatic blood pressure recorder for 24 hours or checking your pressure with an at-home monitor several times a day. Treatment also usually involves a change or addition of medications and investigation of secondary causes – along with key lifestyle changes, including:

  • Eating a well-balanced, low-salt diet
  • Limiting alcohol
  • Enjoying regular physical activity
  • Maintaining a healthy weight
  • Managing stress
  • Taking your medications properly
  • People with resistant hypertension should take the right medications, in the right doses, at the right time. DO NOT take medications or supplements that can boost blood pressure, such as diet pills and stimulants, cyclosporine, natural licorice, ephedra and painkillers and non-steroidal anti-inflammatory agents (NSAIDs), such as ibuprofen and celecoxib.
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More ways to overcome resistance:

If you have reached the maximum dosage of at least three medications and your blood pressure is still high — and lifestyle changes also haven’t helped — your doctor will look for other causes such as kidney disease, Cushing’s disease, or pheochromocytoma (a tumor in an adrenal gland). After that, he or she will explore other underlying issues. For example:

Sleep Apnea

This common condition is marked by repeated pauses in your breathing—lasting from a few seconds to a minute or so—while you sleep. A 2014 study in the Journal of Clinical Sleep Medicine involving almost 300 people who had sleep apnea or were at high risk for heart disease found that sleep apnea quadrupled the odds of having resistant hypertension.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

These include over-the-counter pain relievers like ibuprofen (Advil, Motrin) and naproxen (Aleve). A 2012 study in BMC Cardiovascular Disorders of 1,340 users of NSAIDs and 1,340 users of the non-NSAID painkiller acetaminophen (Tylenol) found that NSAID users had a 2 mm Hg increase in systolic blood pressure compared with acetaminophen users. “If you are taking more than occasional doses to control pain, you should discuss this with your doctor,” says Dr. Fisher.


Excess drinking can elevate blood pressure, Men should limit their intake to no more than two drinks per day, says Dr. Fisher.

New Medication

If you haven’t responded to three standard blood pressure drugs, your doctor might try a less common choice, such as spironolactone (Aldactone) or eplerenone (Inspra).

A 2017 study from the European Society of Cardiology compared various treatments in 314 people with resistant hypertension and found that spironolactone, a diuretic, was more effective than traditional choices for drug therapy. The downside is possible side effects, especially for men, like gynecomastia (enlarged breast tissue) and a rise in potassium, especially for people with kidney disease.

A small study involving 57 people with resistant hypertension published online June 13, 2016, by The Journal of Clinical Hypertension discovered that adding eplerenone to the standard three-drug treatment for 12 weeks lowered systolic blood pressure by almost eight points and diastolic blood pressure by more than four points compared with a control group.

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4 Replies to “How To Deal With Resistant Hypertension”

  1. Why aren’t tests for adrenal tumors, sleep apnea, Cushing’s disease and kidney disease not done BEFORE treating patients with a multitude (up to three!) of medications that have side effects that may compromise a patient’s general health?
    Most BP medications will work and may stop working only after a number of years, and after enough damage to the patient’s health has been done. I don’t think I would be impressed if, after a number of years of chemical treatment, a doctor would suggest to test for the above secondary causes. It is said that 95% of patients have ‘essential hypertension’. What if a particular patient does indeed belong to the 5% with secondary hypertension? It seems to me that most patients are being treated according to statistics and not what is best for them.
    The other thing that would bother me is the ‘trial and error’ approach with medication. I wouldn’t walk a across a bridge that has been constructed by ‘trial and error’, so why are patients so compliant to try ‘trial and error’ with such potent medication?

    1. I understand your questions. It is the same as if people know that eating unhealthy, smoking cigarettes, drinking excessive sugary drinks and living a completely unhealthy lifestyle causes the majority of their health problems, why do they continue to poison themselves. Laziness and the refusal to change. I hope that helps.

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