High Blood Pressure: medications and paying cash

Overview

Hypertension rarely causes symptoms, which is why it is found by measurement and treated to prevent stroke, heart attack, heart failure and kidney disease years later. Guidelines treat to a target, and most people need two medicines at modest doses rather than one at a high dose.

The first-line classes are ACE inhibitors such as lisinopril, angiotensin receptor blockers such as losartan and valsartan, calcium channel blockers such as amlodipine, and thiazide diuretics such as hydrochlorothiazide. Beta blockers such as metoprolol and carvedilol are added when there is also heart disease, and spironolactone is used for pressure that resists the first three classes. Every one of these is a generic with many manufacturers.

Side effects steer the choice: cough with ACE inhibitors, ankle swelling with amlodipine, potassium and kidney effects with ACE inhibitors and ARBs, and dizziness on standing with most of them at first.

Choosing between the options when you pay cash

Because all the first-line drugs are cheap generics, the clinical choice and the cash choice rarely conflict. The cash price of any of them is almost entirely the pharmacy’s dispensing fee and margin, which is why the same prescription can be quoted at very different prices by a chain and an independent. Fixed-dose combination tablets, such as lisinopril with hydrochlorothiazide or amlodipine with valsartan, are also generic and sometimes cheaper than two separate prescriptions because there is one dispensing fee; sometimes the reverse. Ask for both quotes.

The one place cost can bite is a brand-name combination tablet written so that it cannot be substituted. If a brand has been prescribed, it is worth asking whether a generic version, or the generic components as separate tablets, would do. Sacubitril/valsartan, used for heart failure rather than blood pressure alone, is a different product from valsartan and is now also sold as a generic.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Lisinopril
  Tablet, Oral solution (Qbrelis), Combination tablet with hydrochlorothiazide
  Generic: Yes · Once a day
• Losartan
  Tablet, Combination tablet with hydrochlorothiazide
  Generic: Yes · Once or twice a day
• Amlodipine
  Tablet, Oral suspension and oral solution (Katerzia, Norliqva), Several fixed-dose combination tablets
  Generic: Yes · Once a day
• Hydrochlorothiazide
  Tablet, Capsule, Many fixed-dose combination tablets
  Generic: Yes · Once a day
• Valsartan
  Tablet, Oral solution, Combination tablets with hydrochlorothiazide and with amlodipine
  Generic: Yes · Once or twice a day
• Metoprolol
  Immediate-release tablet (tartrate), Extended-release tablet (succinate), Extended-release capsule (succinate)
  Generic: Yes · Twice a day, or once a day extended-release
• Carvedilol
  Immediate-release tablet (twice daily), Extended-release capsule (once daily)
  Generic: Yes · Twice a day
• Spironolactone
  Tablet, Oral suspension (CaroSpir)
  Generic: Yes · Once a day
• Chlorthalidone
  Tablets, Combination tablets with atenolol or azilsartan (separate products)
  Generic: Yes · Once a day
• Olmesartan
  Tablets, Tablets with hydrochlorothiazide (Benicar HCT), amlodipine (Azor) or both (Tribenzor)
  Generic: Yes · Once a day
• Irbesartan
  Tablets, Tablets with hydrochlorothiazide (Avalide and generic)
  Generic: Yes · Once a day
• Telmisartan
  Tablets, Tablets with hydrochlorothiazide, Tablets with amlodipine
  Generic: Yes · Once a day
• Bisoprolol
  Tablets, Tablets with hydrochlorothiazide (Ziac and generic)
  Generic: Yes · Once a day
• Enalapril
  Tablets, Oral solution (Epaned and generics), Tablets with hydrochlorothiazide
  Generic: Yes · Once or twice a day
• Candesartan
  Tablets, Tablets (with hydrochlorothiazide)
  Generic: Yes · Once or twice a day
• Indapamide
  Tablets
  Generic: Yes · Once a day
• Ramipril
  Capsules, Tablets (generic)
  Generic: Yes · Once or twice a day
• Verapamil
  Immediate-release tablets, Extended-release tablets, Extended-release capsules (Verelan and generic)
  Generic: Yes · Three or four times a day
• Triamterene/Hydrochlorothiazide
  Capsules (Dyazide type), Tablets (Maxzide and Maxzide-25 type)
  Generic: Yes · See the guide
• Benazepril
  Tablets, Capsules (with amlodipine), Tablets (with hydrochlorothiazide)
  Generic: Yes · Once or twice a day
• Diltiazem
  Extended-release capsules (several product families), Extended-release tablets, Immediate-release tablets
  Generic: Yes · Once a day
• Nifedipine
  Extended-release tablets, Immediate-release capsules
  Generic: Yes · Once a day
• Atenolol
  Tablets
  Generic: Yes · Once a day
• Propranolol
  Tablets, Extended-release capsules, Oral solution
  Generic: Yes · Two to four times a day
• Guanfacine
  Immediate-release tablets, Extended-release tablets
  Generic: Yes · Once a day
• Clonidine
  Immediate-release tablets, Weekly patch, Extended-release tablets (ADHD; separate blood pressure product)
  Generic: Yes · Twice a day
• Terazosin
  Capsules
  Generic: Yes · Once a day

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• Could my two medicines be combined into one tablet, and would that be cheaper or dearer at this pharmacy?
• Should I have a ninety-day prescription now that my dose is stable?
• When will my potassium and kidney function be checked?
• Is a home blood pressure monitor worth it, and what readings should I report?
• Which over-the-counter painkillers should I avoid?