What is the best medication to start with for initial treatment of hypertension?

Best Medications for Initial Treatment of Hypertension

For initial treatment of hypertension, the recommended first-line medications are thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or long-acting dihydropyridine calcium channel blockers (CCBs). 1

Initial Approach to Medication Selection

Patient Assessment and Risk Stratification

Before selecting medication, consider:

• Presence of comorbidities
• Cardiovascular risk factors
• Target organ damage
• Race/ethnicity
• Age

First-Line Medication Options

1. Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone)
2. ACE inhibitors (e.g., lisinopril)
3. ARBs (e.g., losartan)
4. Long-acting dihydropyridine calcium channel blockers (e.g., amlodipine)

Special Populations and Preferred Initial Agents

• Patients with albuminuria or chronic kidney disease: ACE inhibitors or ARBs 1
• Patients with established cardiovascular disease: ACE inhibitors or ARBs 1
• Black patients: CCBs or thiazide diuretics may be more effective initially 1
• Diabetic patients: ACE inhibitors or ARBs are preferred first-line agents 1

Monotherapy vs. Combination Therapy

When to Consider Monotherapy

• Low-risk patients with mild hypertension (grade 1)
• Elderly patients (>80 years) or frail patients 1
• Initial dose recommendations:
  • Lisinopril: Start with 10 mg once daily, usual range 20-40 mg daily 2
  • Losartan: Start with 50 mg once daily, maximum 100 mg daily 3

When to Consider Combination Therapy

• Blood pressure ≥160/100 mmHg 1
• High cardiovascular risk patients
• When target blood pressure is not achieved with monotherapy

The WHO suggests combination therapy preferably with a single-pill combination as an initial treatment to improve adherence and persistence 1. Single-pill combinations typically include medications from these classes:

• Diuretics (thiazide or thiazide-like)
• ACE inhibitors or ARBs
• Long-acting dihydropyridine calcium channel blockers

Target Blood Pressure Goals

• General population: <140/90 mmHg 1
• Patients with known cardiovascular disease: <130 mmHg systolic 1
• High-risk patients (high CVD risk, diabetes, chronic kidney disease): <130 mmHg systolic 1

Monitoring and Follow-up

• Monthly follow-up after initiation or change in medications until target is reached 1
• Follow-up every 3-5 months for patients under control 1
• Monitor serum creatinine, estimated glomerular filtration rate, and potassium levels when using ACE inhibitors, ARBs, or diuretics 1

Common Pitfalls to Avoid

1. Inappropriate combinations: Avoid combining ACE inhibitors with ARBs 1
2. Ignoring contraindications:
   • ACE inhibitors/ARBs in pregnancy
   • Thiazide diuretics in gout
   • Beta-blockers in asthma 1
3. Inadequate dose titration: Start with lower doses and titrate up as needed
4. Delayed intensification: Don't wait too long to add additional medications if targets aren't met
5. Overlooking adherence issues: Consider single-pill combinations to improve compliance

Algorithm for Medication Selection

1. Assess patient characteristics and comorbidities
2. Select initial therapy based on:
   • For uncomplicated hypertension: Any of the four first-line classes
   • For specific comorbidities: Preferred agent (e.g., ACEi/ARB for diabetes or CKD)
   • For BP ≥160/100 mmHg: Consider initial combination therapy
3. Start with appropriate dosing:
   • Standard starting dose for monotherapy
   • Lower doses of each component for combination therapy
4. Monitor and adjust:
   • Check BP monthly until target achieved
   • Monitor for adverse effects
   • Add additional agents if target not reached

By following this evidence-based approach to selecting initial antihypertensive therapy, clinicians can effectively reduce blood pressure and minimize cardiovascular risk in patients with hypertension.