What is the best medication for managing hypertension (high blood pressure)?

From the Guidelines

The most effective approach to managing hypertension is to use a combination of medications from different drug classes, with a preference for single-pill combinations, as recommended in the 2024 ESC guidelines 1. When treating hypertension, it's essential to consider the individual patient's needs and response to different medications. The major four drug classes, including ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics, are recommended as first-line BP-lowering medications, either alone or in combination 1. Some key points to consider when selecting medications include:

• ACE inhibitors and ARBs are beneficial for patients with diabetes or kidney disease, but should be avoided in pregnancy 1
• Calcium channel blockers are effective in African American patients 1
• Beta-blockers are no longer first-line for uncomplicated hypertension but may be preferred in patients with heart failure or previous heart attacks 1
• Lifestyle modifications, such as reduced sodium intake, regular exercise, weight management, limited alcohol consumption, and smoking cessation, are crucial components of any hypertension treatment plan In terms of specific medications, the following may be considered:
• Thiazide diuretics, such as hydrochlorothiazide 12.5-25mg daily
• ACE inhibitors, such as lisinopril 10-40mg daily
• Angiotensin II receptor blockers, such as losartan 25-100mg daily
• Calcium channel blockers, such as amlodipine 5-10mg daily
• Beta-blockers, such as metoprolol, may be used in certain situations, but are not typically first-line for uncomplicated hypertension 1 It's also important to note that patient-level response to individual BP-lowering drug classes can be heterogeneous, and some patients may benefit from more personalized treatment compared to routine combinations 1. Ultimately, the choice of medication will depend on a variety of factors, including the patient's age, race, comorbidities, potential side effects, and cost, as well as their individual response to different medications 1.

From the FDA Drug Label

Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits Many patients will require more than one drug to achieve blood pressure goals. Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy.

The best medication for managing hypertension is not specified, as different patients may require different treatments based on their individual needs and circumstances. Lisinopril 2 and amlodipine 3 are both indicated for the treatment of hypertension, but the choice of medication should be guided by comprehensive cardiovascular risk management and consideration of additional approved indications and effects. Key factors to consider include:

• The patient's overall cardiovascular risk profile
• The presence of other health conditions, such as diabetes or hyperlipidemia
• The potential for drug interactions or side effects
• The need for additional therapies, such as lipid control or antithrombotic therapy

From the Research

Medication Options for Hypertension

The following medications are commonly used to manage hypertension:

• Thiazide diuretics, such as chlortalidone or hydrochlorothiazide 4
• Angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) 5, 6
• Calcium channel blockers, such as amlodipine 5, 7, 8, 6
• Beta blockers, which may be used in certain cases, such as heart failure with reduced ejection fraction 5

Combination Therapy

Combination therapy with multiple antihypertensive agents may be necessary to achieve adequate blood pressure control:

• More than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents 5
• Combination therapy with a thiazide diuretic, a calcium channel blocker, and an ACEI or ARB may be effective in lowering blood pressure 7, 8
• The single pill triple combination of aliskiren, amlodipine, and hydrochlorothiazide offers a convenient and effective treatment option 7

Specific Patient Populations

Certain patient populations may require special consideration when selecting antihypertensive medication:

• Black patients: at least one agent should be a thiazide diuretic or a calcium channel blocker 5
• Patients with heart failure with reduced ejection fraction: initial treatment with a beta blocker and an ACEI or ARB, followed by add-on therapy with a mineralocorticoid receptor antagonist and a diuretic 5
• Patients with chronic kidney disease and proteinuria: treatment should include an ACEI or ARB plus a thiazide diuretic or a calcium channel blocker 5
• 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 5