What is the recommended initial treatment for starting a patient on antihypertensives (blood pressure medications)?

From the Guidelines

The recommended initial treatment for starting a patient on antihypertensives involves initiating therapy with a single antihypertensive drug, with dosage titration and sequential addition of other agents to achieve the BP target, particularly for adults with stage 1 hypertension and a BP goal of less than 130/80 mm Hg 1. When deciding on the initial antihypertensive medication, several factors should be considered, including the patient's demographics, comorbid conditions, and potential side effects of the medication.

• 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 a good starting point due to efficacy and cost-effectiveness.
• Alternatively, a calcium channel blocker (CCB) such as amlodipine (5-10 mg daily) may be used, particularly in elderly patients or those of African descent who tend to respond better to these agents.
• For patients with diabetes, chronic kidney disease, or heart failure, an angiotensin-converting enzyme (ACE) inhibitor like lisinopril (10-40 mg daily) or an angiotensin II receptor blocker (ARB) such as losartan (25-100 mg daily) is typically preferred due to their renoprotective and cardioprotective effects 1. Treatment should be initiated at a low dose and titrated upward every 2-4 weeks until blood pressure goals are achieved, typically less than 130/80 mmHg for most adults.
• Combination therapy may be necessary if monotherapy fails to achieve target blood pressure, particularly in patients with stage 2 hypertension (BP ≥140/90 mmHg) 1. These medications work through different mechanisms: diuretics reduce blood volume, CCBs relax vascular smooth muscle, while ACE inhibitors and ARBs block the renin-angiotensin-aldosterone system that causes vasoconstriction. It is essential to monitor the patient's blood pressure regularly and adjust the treatment plan as needed to achieve optimal blood pressure control and minimize the risk of cardiovascular disease.

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2. 1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. Dosage should be adjusted according to blood pressure response. The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose. Doses up to 80 mg have been used but do not appear to give greater effect Use with diuretics in adults If blood pressure is not controlled with lisinopril tablets alone, a low dose of a diuretic may be added (e.g., hydrochlorothiazide, 12. 5 mg). After the addition of a diuretic, it may be possible to reduce the dose of lisinopril tablets. The recommended starting dose in adult patients with hypertension taking diuretics is 5 mg once per day.

The recommended initial treatment for starting a patient on antihypertensives is 10 mg of lisinopril once a day for adults.

• The dosage should be adjusted according to blood pressure response.
• The usual dosage range is 20 mg to 40 mg per day.
• If the patient is already taking diuretics, the recommended starting dose is 5 mg once per day 2.

From the Research

Initial Treatment for Hypertension

The recommended initial treatment for starting a patient on antihypertensives involves the use of low-dose thiazide-type diuretics, such as chlorthalidone or hydrochlorothiazide 3, 4, 5, 6.

Choice of Thiazide Diuretic

• Chlorthalidone is often preferred over hydrochlorothiazide due to its better efficacy and cardiovascular outcomes 4, 5, 6.
• Chlorthalidone has a longer half-life and larger volume of distribution, resulting in a more gradual elimination from the plasma compartment 5.
• Hydrochlorothiazide can still be used as an alternative, especially if chlorthalidone is not available 6.

Combination Therapy

• Combination therapy with a renin-angiotensin system (RAS) inhibitor and a low-dose thiazide diuretic can be effective for patients with uncontrolled blood pressure 7.
• Certain combinations, such as a calcium channel blocker and an angiotensin-converting enzyme inhibitor, may have similar or fewer adverse effects and better outcomes than other combinations 4.

Key Points

• Low-dose thiazide diuretics are recommended as initial therapy for most hypertensive patients 3, 6.
• Chlorthalidone is more effective in lowering systolic blood pressure than hydrochlorothiazide, as evidenced by 24-hour ambulatory blood pressure measurements 3.
• Thiazide-type diuretics are useful first-line agents in the treatment of hypertension, as they have been proven to reduce cardiovascular mortality and morbidity 5.