What antihypertensive medication should I start a patient with hypertension on?

First-Line Antihypertensive Medication Selection for Hypertension

For patients with hypertension, the recommended first-line antihypertensive medication should be either a low-dose ACE inhibitor (ACEI) or ARB for non-black patients, and either a low-dose ARB, dihydropyridine calcium channel blocker (DHP-CCB), or thiazide/thiazide-like diuretic for black patients. 1

Patient-Specific Initial Medication Selection Algorithm

Step 1: Assess Patient Demographics and Comorbidities

• Non-Black Patients:

  • Start with low-dose ACEI (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily) 1, 2, 3

• Black Patients:

  • Start with low-dose ARB, DHP-CCB, or thiazide/thiazide-like diuretic 1

Step 2: Consider Special Populations

• Patients with Diabetes or Chronic Kidney Disease:

  • Prefer ACEI or ARB as first-line therapy 1
  • Target BP < 130/80 mmHg 1

• Patients with Known Cardiovascular Disease:

  • Initiate treatment even at SBP 130-139 mmHg 1
  • Target SBP < 130 mmHg 1

• Elderly Patients (>80 years) or Frail Patients:

  • Consider monotherapy with any first-line agent 1
  • Individualize BP targets based on frailty 1

Dosing and Titration

1. Initial Dosing:

   • ACEI (e.g., lisinopril): Start with 10 mg daily 2
   • ARB (e.g., losartan): Start with 50 mg daily 3
   • Consider lower starting doses in patients on diuretics or with possible volume depletion 2, 3

2. Titration:

   • Assess BP response after 2-4 weeks 1
   • If BP not at goal, increase to full dose 1
   • For lisinopril: Titrate to 20-40 mg daily as needed 2
   • For losartan: Titrate to maximum 100 mg daily as needed 3

3. Combination Therapy:

   • If BP remains uncontrolled on maximum dose of initial agent, add a second agent from a different class 1
   • Preferred combinations: ACEI/ARB + DHP-CCB or ACEI/ARB + thiazide/thiazide-like diuretic 1
   • Consider single-pill combinations to improve adherence 1

Important Clinical Considerations

• BP Targets:

  • General population: < 140/90 mmHg 1
  • High-risk patients (CVD, diabetes, CKD): < 130/80 mmHg 1

• Monitoring:

  • Check BP monthly after initiation until target is reached 1
  • Monitor renal function and electrolytes 2-4 weeks after starting ACEI/ARB 2
  • Follow up every 3-5 months once BP is controlled 1

• Common Pitfalls to Avoid:

  • Never combine an ACEI with an ARB due to increased risk of adverse effects without additional benefit 1
  • Avoid starting with high doses, which increases risk of side effects without significantly improving efficacy
  • Don't delay treatment in high-risk patients (those with CVD, CKD, diabetes, or organ damage) 1
  • Be cautious with ACEI/ARBs in women of childbearing potential due to teratogenic risks

Resistant Hypertension Management

If BP remains uncontrolled on three agents (including a diuretic):

• Add spironolactone as fourth-line therapy 1
• If spironolactone is not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1
• Refer to a specialist with expertise in hypertension management 1

The 2020 International Society of Hypertension guidelines and 2022 WHO guidelines provide the most recent and comprehensive evidence-based recommendations for antihypertensive medication selection, emphasizing the importance of patient-specific factors in medication choice while maintaining focus on reducing morbidity and mortality through effective blood pressure control.