Pharmacotherapeutic strategies for treating hypertension in patients with obesity

ABSTRACT

Introduction: Hypertension and obesity are important health challenges that independently increase cardiovascular morbidity and mortality. There is a lack of randomized controlled trials to clearly inform on preferred drug choices to be adopted in clinical practice for the treatment of obesity-related hypertension (OHT). Adequate differentiation of drug classes for preferential use in obesity or the metabolic syndrome aimed at avoiding adverse effects on body weight and the metabolic profile is neglected in this population, at least in part due to the lack of specific pharmacologic recommendations in hypertension guidelines.

Areas covered: The authors summarize and suggest pharmacotherapeutic strategies based on pathophysiologic rationale to achieve blood pressure (BP) control and avoid adverse metabolic consequences in OHT.

Expert opinion: Combinations of various pharmacologic antihypertensive approaches are required in the management of OHT. It is recommended that targeting sympathetic overactivity with a centrally acting sympatholytic agent such as moxonidine should be considered as a preferred second line treatment choice in combination with renin angiotensin system (RAS) blockade, the current first line choice. Though not all obese subjects have sympathetic overdrive, this approach is likely to provide effective control of blood pressure and improve the metabolic profile of patients with OHT along with positive implications for cardiovascular risk reduction.

KEYWORDS:

• Obesity related hypertension
• sympathetic nervous system
• pharmacotherapy
• antihypertensive medications
• centrally acting sympatholytic agent
• moxonidine

Article highlights

• Hypertension remains a significant burden for patients with obesity, leading to significant cardiovascular morbidity and mortality.

• Sustained sympathetic overdrive is a cardinal feature of obesity and contributes to BP elevation.

• Sustained sympathetic overactivity also has adverse metabolic consequences.

• Obesity hypertension is a distinctive form of hypertension that requires specific considerations in planning therapeutic strategies.

• Specific pharmacologic recommendations for the treatment of obesity-related hypertension are a clinically-relevant but an unmet need.

• In addition to weight loss interventions, antihypertensive combination therapy is frequently required and remains central to adequately manage obesity-related hypertension.

• Based on established pathophysiologic considerations, inhibition of the renin-angiotensin system paired with interventions to reduce central sympathetic outflow appears as a preferable therapeutic approach to optimize BP and metabolic control on obesity-related hypertension.

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Declaration of interest

MP Schlaich is supported by an NHMRC Research Fellowship and has received consulting fees, and/or research support from Abbott. None of the other authors declare any conflict of interest relevant to this manuscript. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript is not funded.