Resistant Hypertension

What is resistant hypertension (high blood pressure), and how do you control it?

Less than half of people with hypertension (high blood pressure) reach the blood pressure goal of less than 120/80 mm Hg. This is the goal for many people with uncomplicated hypertension. Why is this the case?

  • Doctors are not treating hypertension aggressively enough.
  • People are not taking their medications as prescribed or are not making lifestyle changes.
  • Some people have resistant hypertension.

Resistant hypertension is a form of hypertension that does not respond well to at least three different drugs. The numbers of people with resistant hypertension ranges from 5% to 30% of people with hypertension. It’s important to remember that resistant hypertension is not the same as uncontrolled blood pressure.

Discuss with your doctor the differences between normal hypertension and other forms of hypertension. This includes white coat hypertension and resistant hypertension.

In nearly all cases, normal hypertension can be controlled and managed.

  • The trick is finding the right drug or combination of drugs.
  • You also have to listen to your doctor’s directions. Some people quit taking their medications because they think their blood pressure is fine. Other people take a lower dose because they don’t like the side effects.
  • Do not be afraid to answer honestly when your doctor asks if you are having any difficulties following your treatment plan.
  • Your doctor can make changes in the treatment plan to make it easier to follow, less expensive, and with fewer side effects.

It is also possible that you have white coat hypertension. This is elevated blood pressure only in the doctor’s office. It might happen even if you are on medication and your blood pressure is fine at home.

  • To help rule this out, your doctor may ask you to use an ambulatory blood pressure monitor. This is a portable device worn on a belt that records your blood pressure many times as you go about your normal day.
  • Another alternative is to monitor your blood pressure at home with a home monitor.
  • If those numbers are consistently lower than in-office measurements, you might have a case of white coat hypertension.

When resistant hypertension is real

Your doctor may find out that your blood pressure is truly resistant. If this is the case, you and your doctor need to consider the following factors1.

Secondary causes

In some people, resistant hypertension can be traced to a specific, treatable condition.

  • One example is obstructive sleep apnea. This is a breathing disorder that results in multiple episodes of breathing cessation during sleep. It also causes loud snoring, frequent nighttime awakening, and daytime sleepiness.
  • Another example is primary aldosteronism. This is overproduction of aldosterone, a blood pressure-boosting hormone. According to some estimates, up to 20% of people with resistant hypertension have this problem.
  • Kidney diseases also can lead to resistant hypertension.

If you have resistant hypertension, your doctor will probably screen you for these conditions. Managing them through medication and lifestyle changes may lower your blood pressure.

Medication as the cause


A rise in blood pressure can be an unfortunate side effect of some drugs and supplements. Common medications include:

Nonsteroidal anti-inflammatory drugs (NSAIDs). These are pain medications including:

  • Aspirin
  • Ibuprofen (Advil, Motrin)
  • Naproxen (Aleve, Naprosyn)
  • Celecoxib (Celebrex)

Note: If you are taking low-dose aspirin as a preventive measure against heart attack or stroke, the benefit may outweigh the small increase in blood pressure that may result.

Acetaminophen (Tylenol) can raise blood pressure, but it has less of an impact than NSAIDs. It may be used as an alternative to taking ibuprofen or another NSAID.

Other medications that can raise blood pressure include:

  • Decongestants
  • Diet pills and any medication or herbal supplement

Your doctor will likely ask about any medications or supplements you are taking. If necessary, they will tell you to stop or take the lowest effective dose.

Improving your treatment

The American Heart Association (AHA) considers hypertension resistant when:

  • Blood pressure remains elevated despite using three or more classes of blood pressure medication at optimal doses.
    • Calcium-channel blocker
    • Diuretic
    • ACE inhibitor or angiotensin II receptor blocker (ARB)
  • Blood pressure requires four or more blood pressure drugs to achieve target goal.

If treating or managing underlying or secondary causes does not lower your blood pressure, other strategies may help. If lifestyle changes and strict adherence to drug regimens does not work, your doctor may intensify your treatment.

  • Increase your dosages or change dosing times
  • Switch your current diuretic with a long-acting one
  • Add a fourth drug called an aldosterone antagonist or blocker

Recent studies suggest that spironolactone may also lower blood pressure in people who have resistant hypertension not caused by primary aldosteronism. The drawback is that you will need monitoring of your blood potassium levels. Aldosterone blockers lower your body’s excretion of potassium in the urine. Extremely high blood potassium levels can lead to potentially dangerous heart arrhythmias.

Other drugs prescribed for treating resistant hypertension include alpha-blockers. These are used only in people with resistant blood pressure. Frequently prescribed alpha-blockers include:

  • Doxazosin (Cardura)
  • Prazosin (Minipress)
  • Terazosin (Hytrin)

Alpha-blockers are not recommended as a first-choice therapy. This is because they can increase the risk of certain heart conditions.

Other classes of antihypertensives that doctors prescribe for blood pressure that is very difficult to control include:

  • Central alpha agonists
  • Direct vasodilators
  • Peripheral-acting adrenergic antagonists

Besides adding different medications, your doctor may also ask you to experiment with the timing of your doses. Studies show that people who take at least one of their blood pressure drugs at bedtime have better blood pressure control.

Tips to stay on track with blood pressure medications

Like most people, you probably forget to take your medications now and then. Maybe you’ve stopped taking your medication because of the cost, side effects, or your drug regimen’s complexity.

You can use several strategies on your own and with your doctor’s help.

  • Remind yourself: Smartphones, tablets, and computers can be set to give you a daily reminder to take your pills. Using a pillbox or paper calendar to mark each time you take your pills can be helpful.
  • Test your blood pressure at home: Studies suggest that people who check their blood pressure routinely at home are more likely to take their medications as directed. Ask your doctor to recommend a home blood pressure device.
  • If your medications are too expensive: Your doctor may be able to prescribe less costly or generic alternatives.
  • If you drug regimen is too complex: Your doctor may be able to prescribe combination pills containing two or more of the drugs you take.
  • If you’re bothered by side effects: Tell your doctor. They can try lowering your dosages. They can work with you to find drugs with similar blood pressure benefits and fewer side effects.
Medication adherence

The World Health Organization defines medication adherence as "the degree to which the person's behavior corresponds with the agreed recommendations from a health care provider." Poor adherence to prescribed regimens can result in serious health impacts including hospitalization and death.

About half of all medications for chronic diseases are not taken correctly. People change or skip doses, stop too soon, don’t take them at all, or never fill their prescriptions.

What to do when you get a new medication:

  • Take notes on what your doctor tells you about the medication.
  • Double check with the pharmacist on how to take the medication.
  • Ask questions to make sure you fully understand the medication. Be clear about when and how to take it.
  • Creating a chart for your daily medication regimen can help you stay on track. So might a pill box with multiple sections. This is helpful if you take more than one medication. This is also helpful if you take medications more than once a day. 
  • If you’re being treated for a chronic condition, check regularly with your doctor about whether you are taking the medication(s) correctly.
  • If you are concerned about or are experiencing side effects, talk to your doctor.
  • Do not take yourself off of medications without the knowledge and guidance of your doctor.
  • If you’re having trouble sticking to your medication, for any reason, talk with your doctor. They may be able to suggest other treatments or refer you to services that can help.




  1. American Heart Association