What is the initial medication regimen for hypertension?

Initial Medication Regimen for Hypertension

For most adults with hypertension, a thiazide-type diuretic should be used as initial therapy, either alone or in combination with other agents depending on blood pressure severity.

Classification and Initial Treatment Approach

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

• First-line therapy: Thiazide-type diuretic for most patients 1
• Alternative first-line options include ACE inhibitors, ARBs, calcium channel blockers (CCBs), or beta-blockers 1
• Initial monotherapy is reasonable with titration and sequential addition of other agents as needed 1
• Starting dose examples:
  • Hydrochlorothiazide: 12.5-25 mg once daily 2
  • Lisinopril (ACE inhibitor): 10 mg once daily, adjusted according to response 3
  • Metoprolol succinate (beta-blocker): 25-100 mg once daily 4

Stage 2 Hypertension (≥160/≥100 mmHg)

• Initiate with 2-drug combination therapy for most patients 1
• Recommended combination: Thiazide-type diuretic plus ACE inhibitor, ARB, beta-blocker, or CCB 1
• Two-drug initial therapy is recommended when BP is >20/10 mmHg above target 1

Special Population Considerations

Patients with Diabetes

• First-line therapy: ACE inhibitor or ARB 5
• Target BP: <130/80 mmHg 1, 5
• If ACE inhibitor/ARB not tolerated, dihydropyridine CCB is the next best option 5
• Avoid combining ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury 5

Patients with Chronic Kidney Disease

• First-line therapy: ACE inhibitor or ARB, especially with albuminuria 5
• Target BP: <130/80 mmHg 1
• Monitor renal function and electrolytes within 1-2 weeks after starting therapy 5

Black Adults

• First-line therapy: Thiazide diuretic or CCB 1
• ACE inhibitors and ARBs are less effective as monotherapy in this population

Medication Selection Tips

Thiazide Diuretics

• Chlorthalidone is preferred over hydrochlorothiazide due to:
  • Longer half-life and more consistent 24-hour BP control 1
  • Better cardiovascular outcomes data 6
  • More effective BP reduction, particularly at night 1
• Starting dose of hydrochlorothiazide: 12.5-25 mg daily 2
• Higher doses (>50 mg) of hydrochlorothiazide do not provide additional BP lowering but increase side effects 7
• Monitor for hypokalemia and hypomagnesemia, which can increase risk of ventricular arrhythmias 7

ACE Inhibitors

• Starting dose of lisinopril: 10 mg once daily 3
• Reduce initial dose to 5 mg if patient is on a diuretic 3
• Monitor for cough, hypotension, hyperkalemia, and acute kidney injury 3
• Contraindicated in pregnancy 5

Combination Therapy Principles

• Follow the AB/CD rule: (ACE inhibitor or ARB) + (Calcium channel blocker or Diuretic) 5
• Fixed-dose combinations improve adherence and may have fewer side effects than higher doses of single agents 8
• Avoid combining ACE inhibitors with ARBs 5

Monitoring and Follow-up

• Check BP within 2-4 weeks after starting or changing medications 5
• Monitor serum creatinine/eGFR and potassium within 1-2 weeks after starting ACE inhibitors, ARBs, or diuretics 5
• Annual monitoring of renal function and electrolytes in stable patients 5

Common Pitfalls to Avoid

• Using high-dose hydrochlorothiazide (>50 mg) which increases metabolic side effects without additional BP lowering 7
• Combining ACE inhibitors with ARBs, which increases adverse effects without additional benefit 5
• Inadequate dosing or failure to add a second agent when BP remains uncontrolled
• Ignoring lifestyle modifications that enhance medication efficacy 9
• Delayed treatment intensification (therapeutic inertia) when BP remains uncontrolled 8

By following this evidence-based approach to initial hypertension treatment, clinicians can effectively reduce cardiovascular risk while minimizing adverse effects.