What are the recommendations for additional medication or therapeutic adjustments?

From the Guidelines

I recommend initiating treatment with an ACE inhibitor or an ARB, in combination with a dihydropyridine CCB or a diuretic, as first-line therapy for hypertension management, as supported by the most recent guidelines 1. This approach is based on the latest evidence from the 2024 ESC guidelines for the management of elevated blood pressure and hypertension, which emphasizes the importance of combination therapy for most patients with confirmed hypertension. The recommended combination therapy includes a RAS blocker (either an ACE inhibitor or an ARB) with a dihydropyridine CCB or diuretic, which has been shown to be effective in reducing blood pressure and cardiovascular disease events. Some key points to consider when implementing this treatment strategy include:

• Convenient timing of medication administration to establish a habitual pattern and improve adherence 1
• Preferred combinations include a RAS blocker with a dihydropyridine CCB or diuretic, with exceptions for patients aged ≥85 years, those with symptomatic orthostatic hypotension, moderate-to-severe frailty, or elevated BP with a concomitant indication for treatment 1
• Fixed-dose single-pill combination treatment is recommended for patients receiving combination BP-lowering treatment 1
• If BP is not controlled with a two-drug combination, increasing to a three-drug combination is recommended, usually a RAS blocker with a dihydropyridine CCB and a thiazide/thiazide-like diuretic, and preferably in a single-pill combination 1 It is essential to monitor patients regularly and adjust the treatment plan as needed to achieve optimal blood pressure control and minimize the risk of cardiovascular disease events, as highlighted in previous guidelines 1.

From the FDA Drug Label

The LIFE study was a multinational, double-blind study comparing losartan and atenolol in 9193 hypertensive patients with ECG-documented left ventricular hypertrophy. Patients with myocardial infarction or stroke within six months prior to randomization were excluded Patients were randomized to receive once daily losartan 50 mg or atenolol 50 mg. If goal blood pressure (<140/90 mmHg) was not reached, hydrochlorothiazide (12.5 mg) was added first and, if needed, the dose of losartan or atenolol was then increased to 100 mg once daily.

The initial dose of atenolol is 50 mg given as one tablet a day either alone or added to diuretic therapy. The full effect of this dose will usually be seen within one to two weeks. If an optimal response is not achieved, the dosage should be increased to atenolol 100 mg given as one tablet a day

The recommendation for additional medication or changes is to add hydrochlorothiazide (12.5 mg) if the goal blood pressure is not reached with losartan 50 mg or atenolol 50 mg. If needed, the dose of losartan or atenolol can be increased to 100 mg once daily. 2 3

• Key points:
  • Add hydrochlorothiazide (12.5 mg) if goal blood pressure is not reached
  • Increase losartan or atenolol dose to 100 mg once daily if needed
• Main considerations:
  • Goal blood pressure: <140/90 mmHg
  • Initial dose: losartan 50 mg or atenolol 50 mg once daily

From the Research

Recommendation for Additional Medication or Changes

The decision to recommend additional medication or changes to existing treatment regimens can be informed by various studies.

• A study from 1992 4 compared the effects of adding an ACE inhibitor (lisinopril) or a diuretic (hydrochlorothiazide) to a beta-blocker (atenolol) in patients with hypertension. The results showed that both combinations were effective in lowering blood pressure, but the ACE inhibitor had a more favorable effect on heart rate.
• Another study from 1997 5 reviewed the use of lisinopril in patients with diabetes mellitus and found that it was effective in lowering blood pressure and preserving renal function, without adversely affecting glycemic control or lipid profiles.
• A study from 2010 6 discussed the underutilization of ACE inhibitors and angiotensin II type 1 receptor antagonists in elderly patients with diabetes mellitus, despite their proven benefits in preventing progression of diabetic renal disease.
• A study from 1997 7 investigated the risk of serious hypoglycemia in older persons using insulin or sulfonylureas and found that specific antihypertensive drug therapy had little impact on this risk.
• However, a study from 2017 8 is not directly relevant to the question of medication changes, as it focuses on the health benefits of physical activity.

Considerations for Medication Changes

When considering changes to medication regimens, the following factors should be taken into account:

• The potential benefits and risks of adding or switching medications, as seen in the study comparing ACE inhibitors and diuretics 4
• The specific needs and health status of the patient, such as the presence of diabetes mellitus or renal disease 5, 6
• The potential for drug interactions or adverse effects, such as hypoglycemia 7