From the Guidelines
The first line treatment for hypertension should include lifestyle modifications and, if necessary, medication with ACE inhibitors or angiotensin receptor blockers (ARBs) as the preferred first-line agents for patients with diabetes or chronic kidney disease, as stated in the 2019 standards of medical care in diabetes 1.
Key Lifestyle Modifications
- Reducing sodium intake to less than 2.3g daily
- Adopting the DASH diet (rich in fruits, vegetables, and low-fat dairy)
- Regular physical activity (150 minutes of moderate exercise weekly)
- Limiting alcohol consumption
- Maintaining a healthy weight
- Smoking cessation
First-Line Medications
- ACE inhibitors (e.g., lisinopril 10-40mg daily)
- Angiotensin II receptor blockers (e.g., losartan 50-100mg daily)
- Thiazide diuretics (e.g., hydrochlorothiazide 12.5-25mg daily)
- Calcium channel blockers (e.g., amlodipine 5-10mg daily)
Patient Characteristics and Medication Choice
The choice of first-line medication depends on patient characteristics, with ACE inhibitors or ARBs preferred for those with diabetes or chronic kidney disease, as they have been shown to reduce cardiovascular events in these populations 1.
Monitoring and Goals
Regular blood pressure monitoring is essential to assess treatment effectiveness, with a goal of below 130/80 mmHg for most adults 1.
Important Considerations
- Combinations of ACE inhibitors and angiotensin receptor blockers, as well as combinations of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors, should not be used 1.
- For patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Therapy should be initiated with the lowest possible dose. Hypertension Initiation Therapy, in most patients, should be initiated with a single daily dose of 25 mg.
The first line treatment for hypertension is chlorthalidone 25 mg once daily. 2
- The recommended initial dose is 25 mg.
- The dose may be increased to 50 mg if the response is insufficient.
- A second antihypertensive drug may be added if additional control is required.
From the Research
First-Line Treatment for Hypertension
The first-line treatment for hypertension is lifestyle modification, which includes:
- Weight loss
- Healthy dietary pattern with low sodium and high potassium intake
- Physical activity
- Moderation or elimination of alcohol consumption 3
- Diet adaptation, such as the dietary approaches to stop hypertension (DASH) diet, which may be considered the most effective treatment for reducing blood pressure 4
Pharmacological Treatment
When lifestyle modifications are not sufficient to control blood pressure, pharmacological treatment may be necessary. The first-line drug therapy for hypertension consists of:
- Thiazide or thiazide-like diuretics, such as hydrochlorothiazide or chlorthalidone 3, 5
- Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), such as enalapril or candesartan 6, 3
- Calcium channel blockers, such as amlodipine 6, 3
Specific Patient Populations
For specific patient populations, such as:
- Black patients, at least one agent should be a thiazide diuretic or a calcium channel blocker 6
- Patients with heart failure with reduced ejection fraction, treatment should include a beta blocker and an ACEI or ARB 6
- Patients with chronic kidney disease and proteinuria, treatment should include an ACEI or ARB plus a thiazide diuretic or a calcium channel blocker 6
- Patients with diabetes mellitus, treatment should be similar to those without diabetes, unless proteinuria is present, in which case combination therapy should include an ACEI or ARB 6