What is the best initial antihypertensive medication for a patient with newly diagnosed hypertension?

From the Guidelines

The best initial antihypertensive medication for a patient with newly diagnosed hypertension is typically an ACE inhibitor or ARB, as recommended by the most recent guidelines 1. For most patients without compelling indications, a thiazide diuretic like hydrochlorothiazide (starting at 12.5-25 mg daily) or chlorthalidone (12.5-25 mg daily) is often recommended as first-line therapy, as they effectively lower blood pressure by promoting sodium and water excretion, reducing blood volume and vascular resistance. Some key points to consider when selecting an initial antihypertensive medication include:

• Patient-specific factors, such as the presence of diabetes, chronic kidney disease, or heart failure, which may prefer ACE inhibitors (like lisinopril 10-40 mg daily) or ARBs (such as losartan 25-100 mg daily) due to their renoprotective and cardioprotective effects 1.
• The use of CCBs (amlodipine 5-10 mg daily) in elderly patients and those of African descent.
• The recommendation against simultaneous use of ACE inhibitors and ARB, as well as the consideration of β-blockers only in patients with a specific indication, such as coronary artery disease or heart failure 1. Treatment should be initiated at a low dose and titrated every 2-4 weeks until blood pressure goal is achieved, with target typically below 130/80 mmHg. Lifestyle modifications, including reduced sodium intake, regular exercise, weight management, and limited alcohol consumption, should accompany medication therapy. It's also important to consider the initial number of antihypertensive medications, with single-pill combinations strongly favored, especially in patients with blood pressure ≥150/90 mmHg, where initial pharmacologic treatment with two antihypertensive medications is recommended 1.

From the FDA Drug Label

The usual initial antihypertensive oral dose of Amlodipine besylate tablets is 5 mg once daily, and the maximum dose is 10 mg once daily. The usual starting dose of losartan is 50 mg once daily. The usual recommended starting dose is 0.7 mg per kg once daily (up to 50 mg total) administered as a tablet or a suspension.

The best initial antihypertensive medication is not explicitly stated in the provided drug labels. However, losartan and amlodipine are both commonly used to treat hypertension, and their starting doses are:

• Losartan: 50 mg once daily
• Amlodipine: 5 mg once daily It is essential to consult a healthcare professional to determine the most suitable medication and dosage for a specific patient. 2, 2, 3

From the Research

Initial Antihypertensive Medication Options

The choice of initial antihypertensive medication depends on various factors, including the patient's medical history, comorbidities, and potential side effects.

• Angiotensin-converting enzyme (ACE) inhibitors are often preferred as initial therapy in patients with diabetes and nephropathy or those with diminished left ventricular function with or without symptoms of heart failure 4.
• ACE inhibitors may cause a fall in blood pressure, which can be severe in some patients, such as those with treated heart failure, severe hypertension on polypharmacy, or renovascular hypertension 5.
• Calcium channel blockers (CCBs) can be used as initial therapy in special situations, but there is little evidence to suggest they offer a major advantage over other antihypertensive agents 4.

Combination Therapy

Combination therapy with an ACE inhibitor or angiotensin II receptor blocker (ARB) and a diuretic or CCB may be effective in patients with uncontrolled hypertension.

• A study comparing losartan-hydrochlorothiazide and losartan-amlodipine combination therapy found similar blood pressure reductions, but losartan-hydrochlorothiazide increased serum uric acid levels in patients with low baseline levels 6.
• Another study found that lisinopril alone or in combination with hydrochlorothiazide effectively lowered blood pressure in patients with essential hypertension without major side effects 7.

Specific Medications

Certain medications have been shown to be effective in specific patient populations.

• Losartan, an ARB, has been found to have antiproteinuric efficacy in non-diabetic proteinuric renal diseases, reducing proteinuria by 50.4% after 20 weeks of treatment 8.
• Amlodipine, a CCB, did not significantly reduce proteinuria in the same study, but both losartan and amlodipine induced similar blood pressure reductions 8.