Strong against Not reviewed, Not changed We recommend additional therapy in refractory hypertension (for those who do not tolerate or are not adequately controlled with triple therapy [i.e., thiazidetype diuretics, ACEI or ARB, and CCBs] described in Recommendation 43) or as supplementary therapy in some clinical indications. Drug classes for consideration can include (not in priority order): a. Aldosterone/mineralocorticoid receptor antagonists (e.g., spironolactone, eplerenone) b. Other potassium-sparing diuretic (i.e., amiloride) c. Alpha adrenergic blockers d. Beta adrenergic blockers e. Non-dihydropyridine calcium channel blockers f. Combined alpha-beta adrenergic blockers g. Peripherally acting antiadrenergic agents (reserpine, pending availability) h. Direct acting vasodilators (e.g., hydralazine, minoxidil) i. Centrally acting antiadrenergic drugs (e.g., clonidine, methyldopa) Strong for Reviewed, New- replaced We recommend against the use of alpha-adrenergic blockers as monotherapy, but this class of agents may be used as supplemental therapy or if warranted by comorbid conditions (e.g., symptomatic prostatic hypertrophy). (Modified from 2004 VA/DoD HTN CPG) Strong against Not reviewed, Deleted In patients with hypertension and chronic kidney disease (reduced kidney function with albuminuria), we recommend treatment with an angiotensin-converting enzyme inhibitor, or angiotensin II receptor blocker for improving kidney outcomes. (Modified from 2004 VA/DoD HTN CPG) Strong for Reviewed, Deleted In African American patients with hypertension, we recommend against using an angiotensin-converting-enzyme inhibitor or angiotensin II receptor blocker as monotherapy. Strong against Reviewed, Not changed 2014 Recommendation Text 2014 Strength of Recommendation Recommendation Category Recommendation Section Number Page In African American patients with hypertension and stage 1-3 chronic kidney disease, we suggest a combination of a thiazide-type diuretic (for cardiovascular protection) with either an angiotensin-converting- enzyme inhibitor or angiotensin II receptor blocker (for renal protection). 