What is the first-line anti-hypertensive medication, including dosage and frequency, for a 40-year-old woman with hypertension (high blood pressure), hyperprolactinemia (elevated prolactin levels), and normal thyroid function (normal T3 and T4 levels), presenting with a blood pressure of 160/90 mmHg?

From the Guidelines

For a 40-year-old woman with hypertension (160/90 mmHg), hyperprolactinemia, and normal thyroid function, the recommended first-line antihypertensive medication would be a calcium channel blocker such as amlodipine at a starting dose of 5 mg once daily. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of choosing an antihypertensive medication that is effective and has a favorable side effect profile 1. Amlodipine is particularly suitable for this patient because it does not adversely affect prolactin levels, which is a consideration given her hyperprolactinemia.

The choice of amlodipine is also supported by its efficacy in lowering blood pressure without significant effects on metabolic parameters or electrolyte balance, making it a versatile option for a wide range of patients, including those with hyperprolactinemia 1. The dosage of 5 mg once daily is a common starting point, allowing for titration to 10 mg daily if necessary to achieve blood pressure targets, typically less than 130/80 mmHg.

Key considerations in managing this patient's hypertension include:

• Monitoring blood pressure regularly to assess the efficacy of the chosen antihypertensive regimen.
• Adjusting the dosage of amlodipine as needed to achieve target blood pressure levels.
• Being aware of potential side effects such as peripheral edema, headache, and flushing, which are generally mild and may diminish over time.
• Considering lifestyle modifications, including diet and exercise, as adjuncts to pharmacologic therapy to optimize blood pressure control and overall cardiovascular health.

Given the patient's presentation and the need to balance blood pressure control with potential effects on prolactin levels, amlodipine at a starting dose of 5 mg once daily is the most appropriate first-line antihypertensive medication, offering a favorable balance of efficacy and tolerability 1.

From the FDA Drug Label

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. The first-line anti-hypertensive medication for this patient is Lisinopril.

• The recommended initial dose is 10 mg once a day.
• 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 2.

From the Research

Patient Profile

• 40-year-old woman with documented hypertension for the last 6 months
• Hyperprolactinemia (elevated prolactin levels) but normal thyroid function (normal T3 and T4 levels)
• Current blood pressure: 160/90 mmHg
• Refused to take medication before, now agrees to treatment

First-Line Anti-Hypertensive Medication

• According to the study 3, thiazide-type diuretics are superior in preventing one or more major forms of cardiovascular disease and are less expensive, making them a preferred choice for first-step antihypertensive therapy.
• However, considering the patient's profile and the need for a specific medication, lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, is a suitable option.
• The study 4 shows that lisinopril is an effective antihypertensive agent with a smooth, gradual blood pressure reduction, and it does not affect heart rate or cardiovascular reflexes.

Dosage and Frequency

• The initial dose of lisinopril can be 10 mg once daily, as stated in the study 3.
• The study 5 also suggests that 5 mg is a safe starting dose for elderly patients, but since this patient is 40 years old, a dose of 10 mg is more appropriate.
• The dosage can be adjusted based on the patient's response to the medication, with a maximum dose of 40 mg once daily, as mentioned in the study 4.

Combination Therapy

• The study 6 shows that initial combination therapy with an ACE inhibitor and a calcium channel blocker achieves superior blood pressure control compared to monotherapy in patients with stage 2 hypertension.
• However, since this patient is just starting treatment, monotherapy with lisinopril is a reasonable initial approach, with the option to add another medication if necessary to achieve blood pressure goals.