Which drug to which patient?

When a decision to treat a given patient is taken, the embarrassing position arises of deciding which drug should first be prescribed. How can the safest choice be made? Should the physician follow a pathophysiological or an empirical approach? There is no doubt that the most rational approach would consist of matching the pharmacological properties of the drug with the pathophysiological disturbances of the patient. However, these are complex and variable, and their precise assessment in every hypertensive patient is hardly practicable. On the other hand, the pharmacological properties of drugs are often multiple, and sometimes imperfectly understood. The practical impossibility of obtaining a satisfactory pathophysiological profile of each hypertensive patient in order to choose the most suitable drug has strengthened the trend toward formulating and using stepped-care programmes. The philosophy behind these is that of lowering blood pressure with agents most likely to be effective with a minimum of untoward effects, of progressing from a simple start, generally prescribing a single drug at a low dose, to more complex therapeutic regimens. There is some evident soundness in this approach, but stepped-care programmes are sometimes criticized as dogmatic, and are contrasted with the individualized approach, the custom-tailoring provided by pathophysiological profiling. Undoubtedly, the first stepped-care programmes, as formulated in the USA in the 1970s, giving no other first choice than a thiazide diuretic, were rigid and had limitations. On the other hand, the 1978 WHO guidelines were more flexible, suggesting a first choice between either a diuretic or a beta-blocker.(ABSTRACT TRUNCATED AT 250 WORDS)