What is the initial antihypertensive medication for a patient with hypertension?

Initial Antihypertensive Medication Selection for Hypertension

A thiazide-type diuretic should be used as the first-line medication for most patients with uncomplicated hypertension, either alone or in combination with other agents. 1

First-Line Medication Selection Algorithm

For Uncomplicated Hypertension:

• First choice: Thiazide-type diuretic (chlorthalidone or hydrochlorothiazide)
  • Starting dose: Hydrochlorothiazide 12.5 mg daily 2, 3 or chlorthalidone 12.5-25 mg daily
  • Thiazides effectively reduce blood pressure and have demonstrated reduction in cardiovascular morbidity and mortality 4

For Specific Patient Populations:

• Black patients: Thiazide diuretic or calcium channel blocker (CCB) 1

  • Example: Hydrochlorothiazide 12.5 mg daily or amlodipine 5 mg daily 5

• Patients with specific comorbidities:

  • Heart failure: ACE inhibitor (e.g., lisinopril) + beta-blocker + diuretic 1
  • Chronic kidney disease: ACE inhibitor or ARB 1
  • Diabetes: ACE inhibitor or ARB 1
  • Thoracic aortic disease: Beta-blocker 1

Treatment Approach Based on Hypertension Severity

Stage 1 Hypertension (140-159/90-99 mmHg):

• Start with single agent: Thiazide diuretic 1
• Initial dose: Hydrochlorothiazide 12.5 mg daily 2
• Titrate dose if needed after 2-4 weeks

Stage 2 Hypertension (≥160/100 mmHg or >20/10 mmHg above target):

• Start with two-drug combination 1:
  • Thiazide diuretic + ACE inhibitor, ARB, beta-blocker, or CCB
  • Example: Hydrochlorothiazide 12.5 mg + lisinopril 10 mg daily 6

Medication Selection Rationale

Thiazide diuretics are recommended as first-line therapy because:

• Proven efficacy in reducing cardiovascular events and mortality 4
• Low cost and favorable safety profile at low doses 3
• Once-daily dosing improves adherence 7
• Extensive clinical trial evidence supporting their use 1

In the largest head-to-head comparison of first-step antihypertensive medications, the thiazide diuretic chlorthalidone was superior to the CCB amlodipine and the ACE inhibitor lisinopril in preventing heart failure 1.

Common Pitfalls to Avoid

1. Underdosing: Start with appropriate doses (e.g., hydrochlorothiazide 12.5 mg daily) and titrate as needed 2, 3

2. Ignoring racial differences: Black patients respond better to thiazide diuretics or CCBs than to ACE inhibitors 1

3. Neglecting comorbidities: Certain conditions warrant specific first-line agents (e.g., ACE inhibitors for diabetes or CKD) 1

4. Inadequate follow-up: Monitor patients every 2-4 weeks until blood pressure is controlled 7

5. Overlooking combination therapy needs: Most patients with hypertension will require two or more medications to achieve target blood pressure 1, 7

If blood pressure remains uncontrolled on a thiazide diuretic alone, add a second agent from a different class (ACE inhibitor, ARB, CCB, or beta-blocker) based on the patient's comorbidities and risk factors 1, 7.