From Clinical guidelines — Diagnosis and treatment manual › Chapter 12: Other conditions · Médecins Sans Frontières, Current online edition
Médecins Sans Frontières guidance on diagnosis, classification and pharmacological treatment of essential hypertension for resource-limited settings.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition
- Audience
- Clinicians working in resource-limited and humanitarian settings
- Evidence
- Expert consensus
- Reviewed
- 22 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF clinical guideline provides practical management protocols for essential hypertension (high blood pressure of undetermined cause) in adults. Hypertension is defined as elevated blood pressure measured three times during three separate consultations over three months. The guideline classifies hypertension into mild (SBP ≥140 or DBP ≥90 mmHg), moderate (SBP ≥160 or DBP ≥100 mmHg) and severe (SBP ≥180 or DBP ≥110 mmHg), with severe cases further distinguished by presence of end-organ damage.
Treatment begins with lifestyle modification for mild uncomplicated cases, whilst pharmacological treatment is indicated for moderate hypertension (SBP ≥160 or DBP ≥100 mmHg), hypertension with cardiovascular disorder, stroke or diabetes, or mild hypertension not controlled by lifestyle changes. Four drug classes are recommended as first-line monotherapy depending on patient characteristics: thiazide diuretics (hydrochlorothiazide 12.5–25 mg daily), ACE inhibitors (enalapril 5–40 mg daily), calcium channel blockers (amlodipine 5–10 mg daily) or beta-blockers (bisoprolol 5–10 mg daily). Target blood pressures are SBP <140 and DBP <90 mmHg (or <80 mmHg in diabetics, 80 years).
Hypertensive emergencies (BP ≥180/110 mmHg with end-organ damage) require intensive care with cautious BP reduction using intravenous labetalol, aiming for 10–15% reduction in the first hour and not exceeding 25% reduction in 24 hours. The guideline emphasises individualised treatment based on comorbidities, regular monitoring every 3–6 months, and patient education on treatment adherence.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Hypertension is classified as mild (SBP ≥140 or DBP ≥90 mmHg), moderate (SBP ≥160 or DBP ≥100 mmHg) or severe (SBP ≥180 or DBP ≥110 mmHg)
- Target blood pressure: SBP <140 and DBP <90 mmHg (general); SBP <140 and DBP <80 mmHg (diabetics); SBP <150 and DBP <90 mmHg (age >80 years)
- Pharmacological treatment indicated for: SBP ≥160 or DBP ≥100 mmHg; hypertension with cardiovascular disorder, stroke or diabetes; or mild hypertension not controlled by lifestyle changes
- First-line monotherapy options: hydrochlorothiazide 12.5–25 mg once daily; enalapril 5–40 mg once daily (start 2.5 mg in elderly/renal impairment); amlodipine 5–10 mg once daily; bisoprolol 5–10 mg once daily
- For mild uncomplicated hypertension, check BP after 4 weeks; add second drug if no improvement; consider triple therapy after further 4 weeks if needed
- Hypertensive emergency (BP ≥180/110 mmHg with end-organ damage): labetalol IV 20 mg over 1 minute, repeat 10 minutes later, then 40 mg doses every 10 minutes (max. 300 mg total)
- In hypertensive encephalopathy, reduce BP by 10–15% in first hour, not exceeding 25% reduction in 24 hours
- Laboratory surveillance: ionogram and serum creatinine every 6–12 months; clinical monitoring every 3 months initially, then every 6 months
Blood pressure classification thresholds
Table extracted from the guideline
| HBP classification | Systolic (SBP) mmHg | Diastolic (DBP) mmHg |
|---|---|---|
| Mild | 140 or over | 90 or over |
| Moderate | 160 or over | 100 or over |
| Severe | 180 or over | 110 or over |
Source: Médecins Sans Frontières, Essential hypertension in adults — MSF Clinical guidelines. Reproduced in summary form.
From the guideline
Verbatim
“The aim is to reduce BP by 10 to 15% within the first hour and to not reduce it more than 25% during the first 24 hours.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute of Georgia, I recognise that essential hypertension represents one of the most prevalent yet under-managed conditions in our region, with cardiovascular disease remaining the leading cause of mortality in Georgia and neighbouring countries. This MSF guideline offers pragmatic, evidence-based protocols that are particularly well-suited to resource-constrained settings across the South Caucasus, with clear BP thresholds, straightforward drug selection algorithms based on comorbidities, and achievable monitoring schedules. I would particularly stress to Georgian clinicians the importance of the stepwise approach—starting with lifestyle modification for mild uncomplicated cases and progressing methodically through monotherapy to combination therapy only after documented treatment failure at 4-week intervals—as this conserves resources whilst optimising outcomes. The realistic implementation challenge for Georgia will be establishing robust follow-up systems for quarterly and six-monthly monitoring in rural regions where patient retention remains problematic, and ensuring uninterrupted supply chains for the four essential antihypertensive classes in primary care facilities nationwide, which will require strengthening our pharmaceutical procurement and distribution systems under the universal health coverage programme.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia has a substantial burden of cardiovascular disease, making essential hypertension management a priority in the national universal health coverage programme. This MSF guideline offers practical, resource-appropriate protocols suitable for Georgian primary care settings, district hospitals and humanitarian contexts across the South Caucasus. The emphasis on low-cost generic medications (hydrochlorothiazide, enalapril, amlodipine, bisoprolol) aligns with Georgia’s essential medicines list. National adaptation should consider local availability of laboratory monitoring (serum creatinine, potassium), capacity for regular follow-up in rural areas, and integration with existing diabetes and cardiovascular disease management protocols. The stepped approach from lifestyle modification to monotherapy to combination therapy is feasible within Georgia’s primary healthcare infrastructure, though challenges remain in patient adherence, continuous medication supply in remote regions, and establishing systematic recall systems for quarterly and six-monthly monitoring.
Questions this guideline answers
Quick answers
When should I start pharmacological treatment for hypertension?
Start antihypertensive medication when SBP is ≥160 or DBP is ≥100 mmHg, or when hypertension is associated with cardiovascular disorder, stroke or diabetes, or when mild hypertension (SBP ≥140 or DBP ≥90 mmHg) is not controlled by lifestyle and dietary changes alone after an adequate trial period.
Which first-line antihypertensive drug should I choose?
For patients with no comorbidities, start with hydrochlorothiazide 12.5–25 mg once daily. For diabetics, use an ACE inhibitor (enalapril starting at 5 mg once daily). For patients over 65 years or with black skin, use a thiazide diuretic or calcium channel blocker. For renal impairment, use an ACE inhibitor. For cardiac disorders, typically use ACE inhibitor plus beta-blocker from the start.
How quickly should I reduce blood pressure in hypertensive emergency?
In hypertensive encephalopathy, aim to reduce BP by 10–15% within the first hour and do not reduce it more than 25% during the first 24 hours. Use labetalol IV 20 mg over at least 1 minute, repeating after 10 minutes if needed, then 40 mg doses every 10 minutes until controlled (maximum 300 mg total). For stroke, do not try to decrease BP during the first 3 days unless SBP is ≥220 or DBP is ≥120 mmHg.
How should I monitor a patient on long-term hypertension treatment?
Check BP and weight every 3 months initially, then every 6 months, then individualise frequency. Monitor ionogram and serum creatinine every 6–12 months depending on the treatment (especially important with diuretics and ACE inhibitors). Educate patients about not stopping treatment abruptly, especially beta-blockers, and to consult for epistaxis, tinnitus, eye floaters or medication side-effects such as cough with ACE inhibitors or oedema with calcium channel blockers.
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- Issuer
- Médecins Sans Frontières
- Guideline
- Clinical guidelines — Diagnosis and treatment manual
- Chapter
- Chapter 12: Other conditions
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition
- Status
- Current
- Published
- 2026-10-14
- Scope
- Essential hypertension in adults
- Audience
- Clinicians working in resource-limited and humanitarian settings
- Evidence
- Expert consensus
- Record history
- Created 22 Oct 2026 · updated 22 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Essential hypertension in adults. In: Clinical guidelines — Diagnosis and treatment manual. MSF; 2026 Oct 14.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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