What is the first line medication for hypertension?

From the Guidelines

The first line medication for hypertension should be either a thiazide diuretic, a calcium-channel blocker, an angiotensin-converting enzyme (ACE) inhibitor, or an angiotensin II receptor blocker (ARB), with the specific choice depending on individual patient factors such as age, race, comorbidities, and potential side effects, as recommended by the most recent guidelines 1.

Key Considerations

• For most patients without compelling indications for specific agents, a thiazide diuretic like hydrochlorothiazide (12.5-25 mg daily) or chlorthalidone (12.5-25 mg daily) is often recommended as initial therapy.
• Alternatively, a calcium-channel blocker (CCB) such as amlodipine (5-10 mg daily) may be used.
• For patients with diabetes or chronic kidney disease, an ACE inhibitor like lisinopril (10-40 mg daily) or an ARB such as losartan (50-100 mg daily) is typically preferred.
• The choice of medication should be guided by the patient's individual characteristics, including age, race, and comorbidities, as well as potential side effects.

Mechanisms of Action

• Diuretics reduce blood volume.
• CCBs relax blood vessels.
• ACE inhibitors and ARBs block the renin-angiotensin system that causes vessel constriction.

Treatment Goals

• Treatment should aim for a blood pressure goal of less than 130/80 mmHg for most adults, with regular monitoring and potential dose adjustments as needed, as supported by recent guidelines 1.

Special Populations

• African American patients often respond better to thiazides or CCBs.
• Younger patients may benefit more from ACE inhibitors or ARBs.
• Patients with diabetes or chronic kidney disease may require more intensive blood pressure management, as recommended by guidelines such as those from the American College of Cardiology/American Heart Association 1 and the European Society of Cardiology 1.

From the FDA Drug Label

Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits The largest and most consistent cardiovascular outcome benefit has been a reduction in the risk of stroke, but reductions in myocardial infarction and cardiovascular mortality also have been seen regularly Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy.

The first line medication for hypertension is not explicitly stated in the provided drug labels. However, lisinopril is indicated for the treatment of hypertension in adult patients and pediatric patients 6 years of age and older to lower blood pressure 2.

• Lisinopril has been shown to be effective in reducing blood pressure in patients with mild to moderate hypertension.
• It is also effective in patients with moderate to severe hypertension.
• The choice of therapy may be guided by considerations such as the patient's demographic characteristics, comorbidities, and other factors. However, the FDA drug label does not provide a direct answer to the question of what the first line medication for hypertension is.

From the Research

First Line Medication for Hypertension

The first line medication for hypertension can vary depending on the patient's specific condition and medical history. However, based on the available evidence, the following options are considered:

• Angiotensin-Converting Enzyme (ACE) Inhibitors: ACE inhibitors are often recommended as the first line treatment for hypertension, especially for patients with diabetes and nephropathy or those with diminished left ventricular function 3.
• Calcium Channel Blockers (CCBs): CCBs are also considered a first line treatment option for hypertension, particularly for patients with certain medical conditions such as ischemic heart disease 3.
• Thiazides: Thiazides, specifically low-dose thiazides, have been shown to be effective in reducing mortality and morbidity in patients with moderate to severe primary hypertension 4.
• Angiotensin II Receptor Blockers (ARBs): ARBs are another option for first line treatment, although there is limited evidence available compared to other classes of drugs 4.
• Combination Therapy: Combination therapy, such as ACE inhibitors plus CCBs, may be considered for patients with stage 2 hypertension or those who require more aggressive blood pressure control 5, 6, 7.

Key Findings

• A study published in 2018 found that first-line low-dose thiazides reduced mortality, stroke, and coronary heart disease in patients with moderate to severe primary hypertension 4.
• Another study published in 2004 found that initial combination therapy with an ACE inhibitor and a CCB achieved superior blood pressure control compared to monotherapy in patients with stage 2 hypertension 5.
• A post hoc analysis of the Avoiding Cardiovascular Events Through Combination Therapy in Patients Living with Systolic Hypertension trial found that combination therapy with an ACE inhibitor and a CCB was more effective in preventing composite cardiovascular events in patients achieving aggressive systolic blood pressure targets and in those with apparent resistant hypertension 6.
• A review of clinical trials found that fixed-dosed combination regimens consisting of a CCB and an angiotensin II type 1 receptor blocker were effective and well-tolerated in patients with hypertension 7.