What is the first line medication for pediatric hypertension (peds htn)?

First-Line Medication for Pediatric Hypertension

The first-line medications for pediatric hypertension are ACE inhibitors, ARBs, long-acting calcium channel blockers, or thiazide diuretics. 1

Indications for Pharmacologic Treatment

Medication therapy should be initiated in children with:

• Persistent hypertension despite lifestyle modifications
• Left ventricular hypertrophy on echocardiography
• Symptomatic hypertension
• Stage 2 hypertension without a clearly modifiable factor (e.g., obesity)
• Any stage of hypertension associated with chronic kidney disease or diabetes mellitus

Medication Selection Algorithm

1. For most children with primary hypertension:

   • ACE inhibitor (e.g., lisinopril)
   • ARB
   • Long-acting calcium channel blocker (e.g., amlodipine)
   • Thiazide diuretic

2. For African American children:

   • Consider starting with a higher initial dose of ACE inhibitor OR
   • Start with a thiazide diuretic or long-acting calcium channel blocker 1

3. For children with hypertension and CKD, proteinuria, or diabetes mellitus:

   • ACE inhibitor or ARB as first-line (unless contraindicated) 1

Dosing and Monitoring

• Start with a single medication at the low end of the dosing range
• Increase dose every 2-4 weeks until:
  • BP is controlled (<90th percentile)
  • Maximum dose is reached
  • Adverse effects occur
• Follow-up every 4-6 weeks until BP normalizes
• If BP is not controlled with a single agent, add a second agent 1

Treatment Goals

• For children <13 years: BP below the 90th percentile
• For adolescents ≥13 years: BP <130/80 mm Hg 1

Evidence Quality and Considerations

The 2017 American Academy of Pediatrics Clinical Practice Guideline provides the most comprehensive and recent evidence-based recommendations for pediatric hypertension management 1. This guideline was developed using a strict evidence-based approach and aligns with adult hypertension guidelines where appropriate 1.

While β-blockers have been used historically, they are not recommended as initial treatment in children due to their expanded adverse effect profile and lack of association with improved outcomes compared to other agents 1.

Special Considerations

• Adolescent females: ACE inhibitors and ARBs are contraindicated in pregnancy. Consider calcium channel blockers or β-blockers in adolescent females of childbearing potential 1

• Medication efficacy: Studies in hypertensive children show that antihypertensive drugs effectively decrease BP with few adverse effects. There are limited comparative studies between different agents, but available data do not show clinically significant differences in BP-lowering efficacy between recommended first-line agents 1, 2

• Lisinopril efficacy in pediatrics: Clinical studies have demonstrated dose-dependent antihypertensive efficacy of lisinopril in pediatric patients 6-16 years of age, with effectiveness across demographic subgroups including age, gender, and race 3

By following these evidence-based guidelines for medication selection in pediatric hypertension, clinicians can effectively manage blood pressure while minimizing adverse effects and improving long-term cardiovascular outcomes.