What is the recommended initial therapy for hypertension?

From the Guidelines

The initial therapy for hypertension should include lifestyle modifications along with medication, with first-line medication options being thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs, depending on patient characteristics and risk factors, as recommended by the most recent guidelines 1. When considering the initial treatment for hypertension, it's essential to take into account the patient's blood pressure severity, risk factors, and any compelling indications such as diabetes or kidney disease.

• For patients with stage 1 hypertension (130-139/80-89 mmHg), lifestyle changes should be tried first, including reduced sodium intake, regular physical activity, weight loss if overweight, limited alcohol consumption, and a diet rich in fruits and vegetables.
• For patients with stage 2 hypertension (≥140/90 mmHg) or those with compelling indications, medication is usually started immediately, with the choice of medication depending on patient characteristics, such as:
  • ACE inhibitors or ARBs for those with diabetes or kidney disease
  • Consideration of race, with calcium channel blockers and thiazides working better in Black patients Medication should be started at a low dose and titrated upward if blood pressure remains uncontrolled, with follow-up typically within 2-4 weeks of initiating therapy to assess efficacy and side effects, as supported by recent guidelines 1. The most recent and highest quality study 1 prioritizes the use of thiazide diuretics, calcium channel blockers, ACE inhibitors, or ARBs as first-line treatment options, highlighting the importance of individualized treatment approaches based on patient-specific factors.
• Thiazide diuretics, such as chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 12.5-50 mg daily, are effective options for many patients.
• Calcium channel blockers, such as amlodipine 2.5-10 mg daily, are also suitable for initial therapy, particularly in certain patient populations.
• ACE inhibitors, like lisinopril 10-40 mg daily, and ARBs, such as losartan 25-100 mg daily, are preferred for patients with diabetes or kidney disease, due to their renoprotective effects and ability to reduce cardiovascular risk, as noted in 1 and 1.

From the FDA Drug Label

The recommended initial dose is 10 mg once a day. The usual starting dose of losartan is 50 mg once daily.

The recommended initial therapy for hypertension is:

• Lisinopril: 10 mg once daily, with a usual dosage range of 20 mg to 40 mg per day administered in a single daily dose 2
• Losartan: 50 mg once daily, with a maximum dose of 100 mg once daily as needed to control blood pressure 3

From the Research

Initial Therapy for High Blood Pressure

The recommended initial therapy for hypertension includes:

• Lifestyle modification, such as weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 4, 5, 6, 7
• First-line drug therapy, which consists of:
  • Thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone 4, 5, 7
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, such as enalapril or candesartan 4, 5, 7, 8
  • Calcium channel blockers, such as amlodipine 4, 5, 7

Blood Pressure Targets

The target blood pressure levels are:

• Less than 130/80 mm Hg for adults under 65 years 4
• Less than 130 mm Hg for adults 65 years and older 4
• Less than 140/90 mm Hg for patients with chronic kidney disease and diabetes mellitus 5, 7

Benefits of Blood Pressure Lowering

Lowering blood pressure has been shown to reduce the risk of:

• Cardiovascular disease events, such as coronary heart disease, heart failure, and stroke 4, 5, 7
• All-cause and cardiovascular mortality 4, 5, 7
• Myocardial infarction 7