What are the initial medication options for treating hypertension?

Initial Medication Options for Treating Hypertension

First-line agents for hypertension management include ACE inhibitors, ARBs, calcium channel blockers, or thiazide diuretics, with the specific choice depending on individual patient characteristics. 1

First-Line Medication Options

The selection of initial antihypertensive medication should be based on:

1. Severity of hypertension:

   • For BP between 130/80 mmHg and 160/100 mmHg: Begin with a single drug
   • For BP ≥160/100 mmHg: Start with two antihypertensive medications 2

2. First-line medication classes:

   • ACE inhibitors (e.g., lisinopril)
   • Angiotensin receptor blockers (ARBs)
   • Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide)
   • Dihydropyridine calcium channel blockers 2, 1, 3

Patient-Specific Considerations

The choice among first-line agents should be guided by:

• Diabetes: ACE inhibitors or ARBs are recommended first-line, especially with albuminuria (UACR ≥30 mg/g) 2, 1
• Coronary artery disease: ACE inhibitors or ARBs are recommended first-line 2
• Chronic kidney disease: ACE inhibitors to slow kidney disease progression 1
• Black patients: Calcium channel blockers are preferred as first-line therapy 1
• Heart failure: ACE inhibitors, ARBs, or beta-blockers 1
• Elderly patients: Gradual dose titration with careful monitoring for orthostatic hypotension 1

Dosing Considerations

• Lisinopril: Initial dose 10 mg once daily, with usual dosage range of 20-40 mg per day 4
• Hydrochlorothiazide: Initial dose is one capsule once daily, with total daily doses not exceeding 50 mg 5
• Combination therapy: More than 70% of hypertensive patients will eventually require at least two antihypertensive agents for adequate blood pressure control 1

Important Clinical Considerations

• Target blood pressure: <130/80 mmHg for adults <65 years and SBP <130 mmHg in adults ≥65 years 3
• Blood pressure reduction benefits: An SBP reduction of 10 mmHg decreases risk of cardiovascular events by approximately 20-30% 3
• Combination therapy: When using diuretics with ACE inhibitors (like lisinopril), start with lower doses (lisinopril 5 mg) 4
• Single-pill combinations: May improve medication adherence in some patients 2

Common Pitfalls to Avoid

• Never combine ACE inhibitors with ARBs due to increased risk of hyperkalemia and acute kidney injury without added benefit 1
• Avoid therapeutic inertia - don't delay intensifying treatment when targets aren't met 1
• Monitor for side effects: Check serum creatinine/eGFR and potassium levels at the start of treatment and periodically for patients on ACE inhibitors, ARBs, or diuretics 1
• Don't ignore lifestyle modifications: Weight loss, DASH diet, sodium reduction, and physical activity can significantly reduce blood pressure 1
• Avoid immediate release nifedipine in hypertensive urgencies 6

Follow-up and Monitoring

• Follow up within 2-4 weeks to evaluate response to treatment
• Monitor BP monthly until target is reached, then every 3-5 months
• Check renal function and electrolytes regularly, especially with ACE inhibitors, ARBs, or diuretics 1

Remember that achieving BP control to <140/90 mmHg is associated with lower rates of stroke, myocardial infarction, and heart failure, making appropriate medication selection and titration essential for reducing cardiovascular morbidity and mortality.