What is the initial management of hypertension with medications?

Initial Management of Hypertension with Medications

For most patients with hypertension, initial pharmacological therapy should include first-line agents such as thiazide diuretics, calcium channel blockers (CCBs), ACE inhibitors, or angiotensin receptor blockers (ARBs), with combination therapy recommended for most patients with stage 2 hypertension (≥140/90 mmHg). 1

Initial Medication Selection Algorithm

Step 1: Assess Hypertension Severity and Risk

• Stage 1 hypertension (130-139/80-89 mmHg):

  • With 10-year ASCVD risk <10%: Start with lifestyle modifications for 3-6 months 1
  • With 10-year ASCVD risk ≥10% or CVD: Initiate single-agent pharmacotherapy plus lifestyle modifications 1

• Stage 2 hypertension (≥140/90 mmHg):

  • Initiate combination therapy with two agents from different classes 1
  • For BP ≥160/100 mmHg: Definitely start with two-drug combination 1

• Very high BP (≥180/110 mmHg):

  • Immediate evaluation and prompt antihypertensive treatment required 1

Step 2: Select Appropriate Medication(s)

First-line agents (choose based on patient characteristics):

1. Thiazide/thiazide-like diuretics (e.g., chlorthalidone, indapamide, hydrochlorothiazide)
2. ACE inhibitors (e.g., lisinopril)
3. ARBs (e.g., candesartan)
4. Dihydropyridine CCBs (e.g., amlodipine)

Special population considerations:

• Black patients: Thiazide diuretic or CCB preferred as initial therapy 1
• Patients with diabetes: ACE inhibitor or ARB preferred 1
• Patients with chronic kidney disease: ACE inhibitor or ARB preferred 1

Combination Therapy Approach

When initiating combination therapy (which is recommended for most patients with stage 2 hypertension):

1. Preferred combinations:

   • ACE inhibitor or ARB + CCB
   • ACE inhibitor or ARB + thiazide diuretic
   • CCB + thiazide diuretic 1

2. Single-pill combinations are recommended when available to improve adherence 1

3. Avoid these combinations:

   • ACE inhibitor + ARB (not recommended due to increased adverse effects without additional benefit) 1
   • ACE inhibitor or ARB + direct renin inhibitor 1

Dosing and Titration

• Start with standard doses (e.g., lisinopril 10 mg daily) 2
• Evaluate effectiveness within 2-4 weeks
• If BP not at goal:
  • Increase dose of initial agent(s), or
  • Add another agent from a complementary class 1

If BP Remains Uncontrolled

• If BP not controlled on three-drug therapy (including a diuretic), consider adding a mineralocorticoid receptor antagonist (spironolactone) 1
• If still uncontrolled, consider adding beta-blockers, alpha-blockers, or other agents 1
• Consider referral to a hypertension specialist 1

Monitoring and Follow-up

• For patients starting antihypertensive medication:
  • Stage 1 hypertension with treatment: Follow-up in 1 month 1
  • Stage 2 hypertension: Follow-up in 1 month 1
  • Very high BP: More frequent monitoring needed 1

Common Pitfalls to Avoid

1. Inadequate initial therapy: Most patients require combination therapy to reach BP goals
2. Therapeutic inertia: Failure to intensify treatment when BP remains above goal
3. Not accounting for white coat hypertension: Consider home BP monitoring or ambulatory BP monitoring 1
4. Ignoring medication adherence: Single-pill combinations improve adherence 1
5. Overlooking lifestyle modifications: These enhance the effectiveness of pharmacologic therapy 1

Remember that lifestyle modifications remain the cornerstone of hypertension management and should be implemented alongside pharmacological therapy. These include weight loss, healthy dietary patterns (especially DASH diet), sodium restriction, increased physical activity, and moderation of alcohol consumption 1, 3.