What is the appropriate initial medication and dosage for treating hypertension?

From the Guidelines

The initial medication for treating hypertension should be a single-pill combination of two major drug classes, including ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics, at a low dose, as recommended by the 2024 ESC guidelines 1. The choice of initial medication depends on patient characteristics, including age, race, comorbidities, and potential side effects.

• For most patients without compelling indications for other medications, a combination of an ACE inhibitor or ARB with a dihydropyridine CCB or a thiazide diuretic is often recommended.
• African American patients often respond better to thiazide diuretics or CCBs, while ACE inhibitors or ARBs are preferred for patients with diabetes or chronic kidney disease.
• The doses of BP-lowering drugs are presented in the Supplementary data online, Tables S7 and S8 1. Some key points to consider when selecting an initial medication include:
• The major four drug classes (ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics) are recommended as first-line BP-lowering medications, either alone or in combination 1.
• An exception is the combination of two RAS blockers, which is not recommended 1.
• When BP is still uncontrolled under maximally tolerated triple-combination therapy, the patient should be considered resistant and referred to an expert centre for appropriate work-up, and the addition of spironolactone should be considered 1. The goal of treatment is to achieve a blood pressure below 130/80 mmHg for most patients, and medications should be titrated upward if blood pressure remains uncontrolled after 2-4 weeks, with regular monitoring of blood pressure 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Hypertension: Initial adult dose is 10 mg once daily. Titrate up to 40 mg daily based on blood pressure response. The appropriate initial medication and dosage for treating hypertension is lisinopril (PO) at an initial adult dose of 10 mg once daily. The dose can be titrated up to 40 mg daily based on blood pressure response. For patients on diuretics, the initial dose should be 5 mg once daily 2.

• Initial dose for pediatric patients with glomerular filtration rate > 30 mL/min/1.73 m^2 is 0.07 mg per kg (up to 5 mg total) once daily.
• For patients with renal impairment, the initial dose may need to be adjusted, with a recommended initial dose of 2.5 mg for patients with creatinine clearance < 10 mL/min or on hemodialysis 2.

From the Research

Initial Medication for Hypertension

The initial medication and dosage for treating hypertension can vary depending on the patient's specific condition and medical history.

• According to 3, angiotensin-converting enzyme (ACE) inhibitors may be preferred as initial therapy in several subsets of hypertensive patients, such as those with diabetes and nephropathy or with diminished left ventricular function.
• The use of ACE inhibitors, such as lisinopril, has been shown to be effective in lowering blood pressure and reducing the risk of cardiovascular events 4.
• Calcium channel blockers (CCBs) may also be used as initial therapy, particularly in patients with certain medical conditions, such as ischemic heart disease 3.
• The combination of an ACE inhibitor and a CCB may be an optimal combination for the treatment of hypertension, as it provides an additional antihypertensive effect and minimizes the probability of adverse effects related to the dose of antihypertensive 5.

Dosage and Combination Therapy

• The dosage of ACE inhibitors, such as lisinopril, can range from 10 to 80 mg given once daily 4.
• The combination of amlodipine and lisinopril has been shown to be effective in lowering blood pressure and achieving target blood pressure in a higher percentage of patients than monotherapy with either drug alone 6.
• The use of fixed combinations, such as the combination of perindopril and amlodipine, may increase compliance with treatment and improve the control of hypertension 5.
• The choice of initial medication and dosage should be individualized based on the patient's specific needs and medical history, and may involve the use of combination therapy to achieve optimal blood pressure control 7, 5, 6.