The place of combination therapy in the treatment of hypertension in 1993.

"Step Care" fell into disuse following the advent of the ACE inhibitors and calcium antagonists. This was partly because the potency of these agents encouraged their use in monotherapy, and partly because of dissatisfaction with ritual treatment using multiple drugs. However monotherapy too has its problems, not the least of which is ritual increase in the dose of the first drug prescribed, leading to prolonged treatment with high doses and hence an increase in side effects. It is therefore important to consider changing to an alternative drug rather than automatically increasing the dose, or adding a second drug. Combination therapy still has a major place in the treatment of hypertension. It is necessary in patients with severe hypertension, with clinical manifestations of target organ damage, or with associated conditions that often help the doctor to choose a rational combination. Even in patients with uncomplicated mild hypertension, the achievement of goal blood pressure requires combination therapy in around half the cases. By choosing two drugs from appropriate classes of agent, it is possible to add the primary actions of drugs acting through different mechanisms, while opposing the homeostatic compensations that limit the fall in blood pressure. Effective combinations therefore maximise hypotensive efficacy while minimising side effects. Effective combinations for the treatment of classical and of systolic hypertension, are discussed.