What are the current guidelines for standard first‑line prescription doses, routes, frequency, and documentation for charting in adult patients without organ impairment?

Standard First-Line Prescription Doses and Routes for Charting

For charting purposes in adult patients without organ impairment, use the following standard first-line doses and routes based on the most current ACC/AHA and specialty society guidelines.

Hypertension

First-line monotherapy options 1, 2, 3:

• ACE Inhibitors:

  • Lisinopril: 10 mg PO daily, titrate to 20-40 mg daily
  • Enalapril: 5 mg PO daily, titrate to 10-40 mg daily in 1-2 divided doses
  • Ramipril: 1.25-2.5 mg PO daily, titrate to 1.25-20 mg daily

• ARBs:

  • Losartan: 25-50 mg PO daily, titrate to 25-100 mg daily
  • Valsartan: 80-160 mg PO daily, titrate to 80-320 mg daily
  • Irbesartan: 150 mg PO daily, titrate to 150-300 mg daily

• Calcium Channel Blockers:

  • Amlodipine: 2.5-5 mg PO daily, titrate to 5-10 mg daily
  • Diltiazem ER: 120-180 mg PO daily, titrate to 120-360 mg daily

• Thiazide Diuretics:

  • Chlorthalidone: 12.5-25 mg PO daily, titrate to 25-50 mg daily (preferred long-acting)
  • Hydrochlorothiazide: 25 mg PO daily, titrate to 25-50 mg daily

• Beta Blockers (age <60 years):

  • Metoprolol succinate: 50-100 mg PO daily, titrate to 50-200 mg daily
  • Atenolol: 25-50 mg PO twice daily, titrate to 25-100 mg twice daily

Target BP: <130/80 mm Hg 2, 3

Heart Failure (Acute Decompensation)

Loop diuretics for volume overload 4:

• Furosemide:

  • IV: 40-160 mg IV once to three times daily (maximum 200 mg/dose)
  • OR continuous infusion: 5-20 mg/hour IV (maximum 40 mg/hour)
  • PO: 20-80 mg PO once to twice daily (maximum 600 mg/day)
  • For patients on home loop diuretics: use 1-2.5 times the home oral dose IV

• Bumetanide:

  • IV: 0.5-4 mg IV once to three times daily (maximum 5 mg/dose)
  • OR continuous infusion: 0.5-2 mg/hour IV (maximum 4 mg/hour)
  • PO: 0.5-2 mg PO once to twice daily (maximum 10 mg/day)

• Torsemide:

  • PO: 10-40 mg PO once daily (maximum 200 mg/day)
  • No IV formulation available in US

Thiazide-type diuretics (adjunctive for diuretic resistance) 4:

• Metolazone: 2.5-5 mg PO once to twice daily (maximum 20 mg/day)
• Chlorothiazide: 0.5-1 g IV once to twice daily (maximum 2 g/day)

Acute Coronary Syndromes

Anticoagulation for STEMI with fibrinolysis 5:

• Enoxaparin:

  • Age <75 years: 30 mg IV bolus, then 1 mg/kg SC every 12 hours (first SC dose shortly after IV bolus)
  • Age ≥75 years: 0.75 mg/kg SC every 12 hours (no IV bolus)
  • Renal impairment (CrCl <30 mL/min): 1 mg/kg SC once daily

• Fondaparinux (with non-fibrin-specific thrombolytics):

  • 2.5 mg IV initially, then 2.5 mg SC once daily (if creatinine ≤3 mg/dL)

ACE inhibitors (within 24 hours if pulmonary congestion or LVEF <40%) 5:

• Start with low doses as listed above in hypertension section
• Contraindicated if SBP <100 mm Hg or ≥30 mm Hg below baseline

Atrial Fibrillation (Pharmacological Cardioversion)

For recent-onset AF (<48 hours) 6:

• Flecainide:

  • PO: 200-300 mg single dose
  • IV: 1.5-3.0 mg/kg over 10-20 minutes
  • Avoid in structural heart disease or ischemic heart disease

• Propafenone:

  • PO: 600 mg single dose
  • IV: 1.5-2.0 mg/kg over 10-20 minutes
  • Avoid in structural heart disease

• Amiodarone (if structural heart disease present):

  • IV: 5-7 mg/kg over 30-60 minutes, then 1.2-1.8 g/day continuous IV or divided oral doses until 10 g total
  • PO (outpatient): 600-800 mg/day in divided doses until 10 g total, then 200-400 mg/day maintenance

• Ibutilide:

  • IV: 1 mg over 10 minutes; may repeat 1 mg if necessary
  • Monitor for QT prolongation and torsades de pointes

Diabetes with Chronic Kidney Disease

For hypertension with diabetic kidney disease and microalbuminuria or macroalbuminuria 7:

• ACE Inhibitors or ARBs (preferred):
  • Use doses as listed in hypertension section above
  • Target BP: <130/80 mm Hg
  • Goal: Higher end of dose range when tolerated

Key principle: ACE inhibitors and ARBs are first-line for slowing progression of diabetic kidney disease, even in normotensive patients with microalbuminuria 7.

Migraine

Acute treatment 8:

• First-line:

  • Ibuprofen: 400-800 mg PO at onset (preferred in pregnancy during 2nd trimester only)
  • Paracetamol/Acetaminophen: 1000 mg PO at onset

• Triptans (if NSAIDs insufficient):

  • Sumatriptan: 50-100 mg PO at onset (may repeat once after 2 hours; maximum 200 mg/24 hours)

Preventive treatment 8:

• First-line:

  • Propranolol: 80-160 mg PO once or twice daily (long-acting formulations)
  • Metoprolol: 50-100 mg PO twice daily or 200 mg modified-release once daily
  • Topiramate: 50-100 mg PO daily (contraindicated in pregnancy)
  • Candesartan: 16-32 mg PO daily

• Second-line:

  • Amitriptyline: 10-100 mg PO at bedtime

Important Charting Considerations

Route abbreviations:

• PO = oral
• IV = intravenous
• SC = subcutaneous

Frequency abbreviations:

• Daily = once per day
• BID = twice daily
• TID = three times daily

Critical documentation elements:

1. Always document exact dose, route, and frequency
2. Note any dose adjustments for renal or hepatic function (even if none needed, state "no adjustment required")
3. Document indication for medication
4. Record baseline parameters (BP, heart rate, weight, creatinine) before starting therapy
5. Note any contraindications considered and ruled out

Common pitfalls to avoid:

• Do not switch between enoxaparin and UFH (increased bleeding risk) 5
• Do not combine ACE inhibitor with ARB (no benefit, increased harm) 1
• Do not use beta blockers as first-line in uncomplicated hypertension age ≥60 years 1
• Avoid abrupt cessation of beta blockers (risk of rebound hypertension/ischemia) 2, 3
• Monitor potassium when using ACE inhibitors, ARBs, or aldosterone antagonists 1, 2