What is the initial therapy for a patient with stage 2 hypertension?

From the Guidelines

The initial therapy for a patient with stage 2 hypertension (blood pressure ≥140/90 mmHg) should involve the use of drugs from any of the following three classes of pharmacologic anti-hypertensive medications as an initial treatment: thiazide and thiazide-like agents, angiotensin converting-enzyme inhibitors, angiotensin receptor blockers, or long-acting dihydropyridine calcium channel blockers, as recommended by the World Health Organization 1. The recommended approach typically involves a combination of lifestyle modifications and pharmacological therapy. Lifestyle modifications should include sodium restriction (<2.3g/day), regular physical activity (150 minutes of moderate-intensity exercise weekly), weight reduction if overweight, limiting alcohol consumption, and following a DASH diet rich in fruits, vegetables, and low-fat dairy products. Some key points to consider in the management of stage 2 hypertension include:

• The use of thiazide diuretics, such as hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily, as a first-line agent, especially in black patients, including those with diabetes mellitus 1.
• The initiation of 2 antihypertensive agents from different classes is recommended when the average SBP and DBP are more than 20 and 10 mm Hg above target, respectively, for patients with stage 2 hypertension 1.
• Patients with stage 2 hypertension and an average BP of 160/100 mm Hg or higher should be treated promptly, should be carefully monitored, and should have prompt adjustment of their regimen until control is achieved 1.
• Blood pressure should be monitored regularly, with follow-up within 2-4 weeks to assess medication effectiveness and adjust therapy if needed, as recommended by various guidelines 1. This aggressive initial approach is justified because stage 2 hypertension carries significant cardiovascular risk, and prompt blood pressure control reduces the likelihood of complications such as stroke, heart attack, heart failure, and kidney disease.

From the FDA Drug Label

The recommended initial dose is 10 mg once a day. Dosage should be adjusted according to blood pressure response. The usual starting dose of losartan is 50 mg once daily.

The initial therapy for a patient with stage 2 hypertension is 10 mg of lisinopril once daily or 50 mg of losartan once daily. The dosage should be adjusted according to blood pressure response.

• Lisinopril: The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose.
• Losartan: The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure. 2 3

From the Research

Initial Therapy for Stage 2 Hypertension

The initial therapy for a patient with stage 2 hypertension, characterized by a blood pressure of 156/94, involves the use of antihypertensive medications.

• The choice of initial therapy is guided by various factors, including the presence of compelling indications such as diabetes, kidney disease, or heart failure.
• According to the study 4, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are commonly recommended as first-line therapy for hypertension.
• However, the study 4 suggests that ARBs may be associated with fewer adverse events, such as cough and angioedema, compared to ACE inhibitors.
• Another study 5 found that ACE inhibitors and ARBs have similar effects on total mortality and cardiovascular events, but ARBs may have a slightly lower incidence of withdrawals due to adverse events.

Comparison of ACE Inhibitors and ARBs

• A systematic review 6 compared the effectiveness of ACE inhibitors and ARBs for treating essential hypertension and found that both classes of medications have similar long-term effects on blood pressure.
• The review 6 also noted that ACE inhibitors are associated with a greater risk of cough, while ARBs may have fewer withdrawals due to adverse events.
• A multinational cohort study 7 compared the first-line effectiveness and safety of ACE inhibitors and ARBs, but the text of the study is not available.

Guideline Recommendations

• The study 8 noted that US hypertension guidelines recommend ACE inhibitors or ARBs as first-line antihypertensive therapy in the presence of albuminuria (urine albumin/creatinine ratio ≥300 mg/g).
• However, the study 8 found that there is a significant gap in preventive care delivery for adults with hypertension and albuminuria, with many patients not receiving ACE inhibitor or ARB therapy.
• The choice of initial therapy should be individualized based on patient characteristics, medical history, and the presence of compelling indications, as recommended by guidelines 4, 5, 6.