Titrate the third drug up to the maximum recommended dose to achieve goal BP C Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination Initiate therapy with 2 drugs simultaneously, either as 2 separate drugs or as a single pill combination. Some committee members recommend starting therapy with 2 drugs when SBP is >160 mm Hg and/or DBP is >100 mm Hg, or if SBP is >20 mm Hg above goal and/or DBP is >10 mm Hg above goal. If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose. Abbreviations: ACEI, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; DBP, diastolic blood pressure; SBP, systolic blood pressure. 2014 Guideline for Management of High Blood Pressure Special Communication Clinical Review & Education jama.com JAMA Published online December 18, 2013 E11 ing entities and encourage continued attention to rigorous meth- ods in guideline development, thus raising the standard for future guidelines. Discussion The recommendations based on RCT evidence in this guideline dif- fer from recommendations in other currently used guidelines sup- guidelines recommended treatment to lower BP goals in patients with diabetes and CKD based on observational studies.12 Recently, several guideline documents such as those from the American Dia- betesAssociationhaveraisedthesystolicBPgoalstovaluesthatare Other guidelines such as those of the European Society of Hyper- tension also recommend a systolic BP goal of lower than 150 mm Hg, albeit in patients older than 80 years (not 60 years as recom- Thischanginglandscapeisunderstand- ablegiventhelackofclearRCTevidenceinmanyclinicalsituations. 