What is the initial medication for a 35-year-old male with stage two hypertension?

From the Guidelines

For a 35-year-old male with stage two hypertension, the initial medication recommendation is typically a combination of two first-line antihypertensive agents, such as a RAS blocker (either an ACE inhibitor or an ARB) with a dihydropyridine CCB or diuretic, as recommended by the 2024 ESC guidelines 1. This approach is supported by the most recent and highest quality evidence, which suggests that combination therapy is more effective in reducing blood pressure and cardiovascular disease events compared to monotherapy. The specific combination of medications may vary depending on individual patient factors, but the general principle of using a combination of two first-line agents is a key recommendation. Some examples of suitable combinations include:

• An ACE inhibitor like lisinopril 10-20 mg daily, plus a dihydropyridine CCB like amlodipine 5-10 mg daily
• An ARB like losartan 50-100 mg daily, plus a thiazide diuretic like hydrochlorothiazide 12.5-25 mg daily
• A dihydropyridine CCB like amlodipine 5-10 mg daily, plus a diuretic like chlorthalidone 12.5-25 mg daily It is essential to monitor the patient's blood pressure and adjust the medication regimen as needed to achieve optimal control, while also implementing lifestyle modifications such as reduced sodium intake, regular exercise, weight management, and limited alcohol consumption. The 2024 ESC guidelines 1 provide a comprehensive framework for the management of hypertension, and their recommendations should be followed to ensure the best possible outcomes for patients with stage two hypertension. In contrast to older guidelines, such as the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1, the 2024 ESC guidelines provide more up-to-date and evidence-based recommendations for the management of hypertension. Therefore, the 2024 ESC guidelines should be prioritized when making treatment decisions for patients with stage two hypertension.

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2. 1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. The starting medication for stage two hypertension in a 35-year-old male is lisinopril (PO) with a recommended initial dose of 10 mg once a day 2.

• The 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.

From the Research

Initial Medication for Stage Two Hypertension

The initial medication for a 35-year-old male with stage two hypertension is typically an angiotensin-converting enzyme (ACE) inhibitor.

• Lisinopril is an example of an ACE inhibitor that has been shown to be effective in lowering blood pressure in patients with essential hypertension 3, 4.
• The usual therapeutic dosage of lisinopril is 20 to 80 mg once daily 3.
• Lisinopril has been compared to other antihypertensive agents, such as hydrochlorothiazide, atenolol, metoprolol, and nifedipine, and has been found to be at least as effective 3, 4.

Considerations for Patients with Impaired Renal Function

• Lisinopril is excreted unchanged by the kidney and can be used in patients with impaired renal function 5.
• However, the dosage of lisinopril may need to be adjusted in patients with severe renal impairment 5.
• In patients with renovascular hypertension, lisinopril has been shown to be effective in reducing blood pressure and improving renal function 6.

Alternative Therapies

• If hypertension is not adequately controlled with ACE inhibitors, alternative therapies such as beta-blockers or calcium-channel blockers may be considered 7.
• The choice of alternative therapy will depend on the individual patient's needs and medical history.