What oral antihypertensive (blood pressure-lowering) medications are initially prescribed to patients with hypertension?

From the Guidelines

First-line oral antihypertensives should include ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers, with the choice depending on patient characteristics, such as diabetes, chronic kidney disease, or coronary artery disease. When initiating treatment for hypertension, the following options are recommended:

• ACE inhibitors (e.g., lisinopril 10-40mg daily)
• ARBs (e.g., losartan 25-100mg daily)
• Thiazide-like diuretics (e.g., hydrochlorothiazide 12.5-25mg daily)
• Dihydropyridine calcium channel blockers (e.g., amlodipine 2.5-10mg daily) 1. For patients with diabetes and established coronary artery disease, ACE inhibitors or ARBs are preferred as first-line therapy for hypertension 1. In individuals with albuminuria, initial treatment should include an ACE inhibitor or ARB to reduce the risk of progressive kidney disease 1. It is essential to start with a low dose and titrate upward every 2-4 weeks until blood pressure goal is achieved, and many patients may require combination therapy using medications with complementary mechanisms. Lifestyle modifications, including sodium restriction, weight loss, regular exercise, and limiting alcohol consumption, should accompany pharmacotherapy for optimal blood pressure control. The choice of antihypertensive medication should be guided by the patient's individual characteristics and comorbidities, with consideration of potential side effects such as cough with ACE inhibitors, edema with calcium channel blockers, or electrolyte disturbances with diuretics 1.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION 2.1 Adults The usual initial antihypertensive oral dose of Amlodipine besylate tablets is 5 mg once daily, and the maximum dose is 10 mg once daily.

INDICATIONS & USAGE 1. 1 Hypertension Lisinopril tablets USP are indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure.

CLINICAL STUDIES ... An antihypertensive effect of lisinopril was seen with 5 mg of lisinopril in some patients However, in both studies blood pressure reduction occurred sooner and was greater in patients treated with 10 mg, 20 mg or 80 mg of lisinopril than patients treated with 5 mg of lisinopril.

Oral Antihypertensives to start patients on include:

• Amlodipine: 5 mg once daily
• Lisinopril: 5 mg to 10 mg once daily, with 10 mg being more effective in some patients 2, 3, 3

From the Research

Oral Antihypertensives

• The choice of oral antihypertensives depends on various factors, including the patient's medical history, age, and other health conditions.
• According to the study 4, angiotensin II receptor blockers (ARBs) or angiotensin-converting enzyme inhibitors (ACEIs) are often combined with calcium channel blockers (CCBs) and/or thiazide diuretics to improve blood pressure control.
• The study 5 suggests that combining a calcium channel blocker with an angiotensin II type 1 receptor blocker can be an effective treatment option for hypertension.
• Specific oral antihypertensives that may be started in patients include:
  • Olmesartan, an ARB, which can be used alone or in combination with other medications 4
  • Amlodipine, a CCB, which can be used alone or in combination with other medications 5, 6, 7
  • Lisinopril, an ACEI, which can be used alone or in combination with other medications 8, 6, 7
  • Losartan, an ARB, which has been shown to have a similar antihypertensive effect to amlodipine and lisinopril, but with superior tolerability 7
• The study 8 recommends starting with a low dose of lisinopril, such as 10 mg once a day, and adjusting as needed.
• The study 7 found that losartan, amlodipine, and lisinopril all had similar antihypertensive effects, but losartan had fewer side effects.

Combination Therapy

• Combination therapy with two or more antihypertensive agents can be more effective than monotherapy in achieving blood pressure goals 4, 5
• The study 4 suggests that a triple fixed-dose combination of an ARB, a CCB, and a thiazide diuretic can be a rational treatment option for patients who require multiple medications to control their blood pressure.
• The study 6 found that combination therapy with amlodipine and lisinopril was not superior to monotherapy with chlorthalidone in reducing the risk of end-stage renal disease or a 50% or greater decrement in glomerular filtration rate.