What oral antihypertensives (blood pressure medications) are recommended for managing hypertension?

Recommended Oral Antihypertensives for Managing Hypertension

The recommended first-line oral antihypertensives for hypertension include ACE inhibitors, ARBs, calcium channel blockers (CCBs), and thiazide/thiazide-like diuretics, typically initiated as a combination therapy for most patients with confirmed hypertension. 1

First-Line Medications

The major four drug classes recommended as first-line therapy are:

1. Angiotensin-Converting Enzyme (ACE) inhibitors (e.g., lisinopril)
2. Angiotensin Receptor Blockers (ARBs) (e.g., valsartan, candesartan)
3. Calcium Channel Blockers (CCBs) - dihydropyridine type (e.g., amlodipine)
4. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)

Initial Treatment Approach

• For most patients with confirmed hypertension, a single-pill combination containing two of these major drug classes at low doses is recommended
• The combination of two RAS blockers (ACE inhibitor + ARB) is NOT recommended due to increased risk of adverse effects

Population-Specific Recommendations

For Black Patients

• Initial treatment should include a diuretic or a CCB, either alone or with a RAS blocker 1
• For Black patients from Sub-Saharan Africa, combination therapy including a CCB with either a thiazide diuretic or a RAS blocker is recommended 1

Treatment for Resistant Hypertension

When blood pressure remains uncontrolled despite maximal doses of a triple combination therapy (RAS blocker + CCB + diuretic), the following options are recommended:

1. Add low-dose spironolactone (first choice) 1
2. If spironolactone is not tolerated or contraindicated:
   • Eplerenone (may need higher doses of 50-200 mg)
   • Amiloride
   • Higher dose thiazide/thiazide-like diuretic
   • Loop diuretic
3. Beta-blockers (if not already indicated) - preferably vasodilating types like labetalol, carvedilol, or nebivolol 1
4. Other options:
   • Alpha-blockers (e.g., doxazosin)
   • Centrally acting medications (e.g., clonidine)
   • Hydralazine 1

Acute Hypertensive Management

For severe hypertension requiring immediate treatment:

• IV labetalol
• Oral methyldopa
• Nifedipine
• IV hydralazine (second-line option) 1

For hypertensive emergencies with specific organ involvement:

• Malignant hypertension: Labetalol (first-line), alternatives include nitroprusside, nicardipine, urapidil 1
• Hypertensive encephalopathy: Labetalol (first-line), alternatives include nitroprusside, nicardipine 1
• Acute coronary events: Nitroglycerin (first-line), alternatives include urapidil, labetalol 1
• Acute cardiogenic pulmonary edema: Nitroprusside or nitroglycerin with loop diuretic 1

Common Pitfalls and Caveats

1. Avoid combination of two RAS blockers (ACE inhibitors and ARBs) due to increased risk of adverse effects without additional benefit

2. Monitor for electrolyte abnormalities, especially when using diuretics

3. Consider comorbidities when selecting antihypertensive medications:

   • Heart failure: RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists are preferred 1
   • Coronary artery disease: RAS blockers and beta-blockers with or without CCBs 1
   • Previous stroke: RAS blockers, CCBs, and diuretics 1
   • Chronic kidney disease: RAS blockers are preferred

4. Medication adherence is critical - single-pill combinations may improve compliance

5. Minoxidil should only be considered if all other pharmacological agents prove ineffective in resistant hypertension due to multiple side effects 1

Adjunctive Therapies

• Aspirin: Consider 75 mg daily in patients aged ≥50 years with controlled BP (<150/90 mmHg) who have target organ damage, diabetes, or 10-year cardiovascular disease risk ≥20% 1

• Statins: Recommended for patients with hypertension who have established cardiovascular disease or a 10-year risk of cardiovascular disease ≥20% 1

Remember that lifestyle modifications remain a cornerstone of hypertension management alongside pharmacological therapy, and blood pressure targets should be individualized based on age, comorbidities, and risk factors.