What first‑line medications should be recommended for adult patients in primary care for common conditions such as hypertension, hyperlipidemia, type 2 diabetes, bacterial sinusitis, community‑acquired pneumonia, uncomplicated urinary tract infection, anxiety/depression, mild pain, and intermittent asthma?

First-Line Drug List for Primary Care Practitioners

For adult patients in primary care, the essential first-line medications are: thiazide diuretics (chlorthalidone preferred) or ACE inhibitors for hypertension; metformin for type 2 diabetes; moderate-intensity statins for hyperlipidemia; amoxicillin for bacterial sinusitis; amoxicillin or doxycycline for community-acquired pneumonia; nitrofurantoin or fosfomycin for uncomplicated UTI; SSRIs for depression/anxiety; acetaminophen or NSAIDs for mild pain; and short-acting beta-agonists for intermittent asthma.

Hypertension

First-line monotherapy options (choose based on patient characteristics):

• Thiazide/thiazide-like diuretics (Grade A) - chlorthalidone is superior to other agents for preventing heart failure 1, 2, 3
• ACE inhibitors (Grade B) - avoid as first-line in Black patients (Grade A) 2
• ARBs (Grade B) - good alternative if ACE inhibitor not tolerated 2
• Long-acting calcium channel blockers (Grade B) 2
• Beta-blockers - only for patients <60 years (Grade B); NOT recommended ≥60 years (Grade A) 2

Key decision points:

• Age <60 years: Any of the above except consider beta-blocker
• Age ≥60 years: Avoid beta-blockers as first-line
• Black patients: Start with thiazide diuretic or CCB, NOT ACE inhibitor
• Target BP: <140/90 mmHg for most patients 2

Combination therapy: If starting with two drugs (stage 2 hypertension, BP >20/10 mmHg above target), use ACE inhibitor + CCB (Grade A) or ARB + CCB (Grade B) 2

Critical pitfall: Never combine ACE inhibitor + ARB (Grade A) 1, 2

Type 2 Diabetes

Metformin is the foundation of treatment for most patients with type 2 diabetes, particularly those who are overweight - it delays premature mortality regardless of achieved glucose levels 4.

Target: A1c <8% for most patients (individualize based on comorbidities) 4

If hypertensive with diabetes:

• ACE inhibitor or ARB for patients with cardiovascular disease, kidney disease, or microalbuminuria (Grade A) 5, 6
• Target BP: 130/80 mmHg 5, 6

Hyperlipidemia

Moderate-intensity statins are superior to other drugs for cholesterol reduction 4.

Targets:

• LDL <100 mg/dL for most patients
• LDL <70 mg/dL if diabetes + coronary artery disease 4

Bacterial Sinusitis

Amoxicillin remains first-line for uncomplicated bacterial sinusitis in adults. Use high-dose amoxicillin (1g three times daily) if resistance is a concern.

Community-Acquired Pneumonia (CAP)

Outpatient without comorbidities:

• Amoxicillin as beta-lactam monotherapy for uncomplicated cases 7
• Alternative: Doxycycline or macrolide

Outpatient with comorbidities:

• Amoxicillin-clavulanate or cephalosporin PLUS macrolide
• OR respiratory fluoroquinolone (levofloxacin, moxifloxacin) alone

Inpatient non-ICU:

• Beta-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam) PLUS macrolide
• OR respiratory fluoroquinolone alone

Critical update: Healthcare-associated pneumonia has been eliminated as a treatment category 7. Do NOT routinely use corticosteroids 8, 7.

Uncomplicated Urinary Tract Infection (UTI)

First-line agents (prioritize to minimize resistance and "collateral damage"):

• Nitrofurantoin 100mg twice daily × 5 days
• Fosfomycin-trometamol 3g single dose
• Pivmecillinam (if available)

Avoid as first-line:

• Trimethoprim-sulfamethoxazole (resistance rates >20% in many regions) 9
• Fluoroquinolones (reserve for pyelonephritis; causes collateral damage) 9

Rationale: Fosfomycin, nitrofurantoin, and mecillinam exhibit minimal "collateral damage" (selection of multi-resistant pathogens), whereas fluoroquinolones and cephalosporins should be preserved for life-threatening infections 9.

Important consideration: Recent data suggests opioids, PPIs, and even metformin may correlate with higher UTI risk than SGLT2 inhibitors in diabetic patients 10.

Anxiety and Depression

SSRIs (Selective Serotonin Reuptake Inhibitors) are first-line:

• Sertraline, escitalopram, or fluoxetine
• Start low, titrate slowly
• Allow 4-6 weeks for full effect

Mild Pain

Stepwise approach:

1. Acetaminophen 650-1000mg every 6 hours (max 4g/day)
2. NSAIDs (ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily)
   • Use lowest effective dose for shortest duration
   • Consider GI protection (PPI) if risk factors present

Avoid opioids for mild pain - recent evidence shows opioids correlate with increased complications including UTIs in diabetic patients 10.

Intermittent Asthma

Short-acting beta-agonist (SABA):

• Albuterol (salbutamol) inhaler 2 puffs as needed for symptoms
• If using >2 days/week, patient needs step-up therapy (add inhaled corticosteroid)

---

Critical Prescribing Principles

Avoid these combinations:

• ACE inhibitor + ARB (increases harm without benefit) 1, 2
• Non-dihydropyridine CCB + beta-blocker (caution with bradycardia) 1
• Trimethoprim-sulfamethoxazole for UTI if local resistance >20% 9

Monitor closely:

• Potassium and renal function when starting ACE inhibitors or ARBs 6
• Hypokalemia with thiazide diuretics 2
• Blood pressure response within 1 month of starting antihypertensives 6

Age-specific considerations:

• Patients ≥60 years: Avoid beta-blockers for uncomplicated hypertension 2
• Patients <60 years: Beta-blockers are acceptable first-line 2

This formulary prioritizes medications with the strongest evidence for reducing mortality and morbidity while minimizing adverse effects and antimicrobial resistance.