What is the initial blood pressure (BP) medication to prescribe for a patient with newly diagnosed hypertension?

Initial Blood Pressure Medication Selection for Newly Diagnosed Hypertension

Thiazide-type diuretics should be used as initial therapy for most patients with newly diagnosed hypertension, either alone or in combination with another agent such as an ACE inhibitor or ARB. 1

Initial Medication Selection Algorithm

Step 1: Assess Severity of Hypertension

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

  • Start with a single agent: Thiazide-type diuretic 1
  • Chlorthalidone is preferred over hydrochlorothiazide due to superior 24-hour blood pressure control 2
  • Starting dose: Chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 12.5-25 mg daily

• Stage 2 Hypertension (BP ≥160/100 mmHg):

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

Step 2: Consider Compelling Indications

Certain conditions warrant specific first-line agents:

1. Diabetes or Chronic Kidney Disease:

   • ACE inhibitor or ARB is recommended first-line 1
   • Example: Lisinopril 10 mg daily (titrate to 20-40 mg) 3 or losartan 50 mg daily (titrate to 100 mg) 4

2. Albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g):

   • ACE inhibitor or ARB is recommended first-line 1
   • Maximum tolerated dose for optimal renoprotection 1

3. Established Coronary Artery Disease:

   • ACE inhibitor or ARB is recommended first-line 1

Practical Considerations

Dosing

• Start with lower doses and titrate up based on response
• For thiazide diuretics: Low-dose therapy (12.5 mg hydrochlorothiazide or 6.25-12.5 mg chlorthalidone) can provide significant BP reduction with fewer metabolic side effects 5, 2
• For ACE inhibitors: Start lisinopril at 10 mg daily (5 mg if on diuretics) and titrate to 20-40 mg 3
• For ARBs: Start losartan at 50 mg daily (25 mg if volume depleted) and titrate to 100 mg 4

Monitoring

• Check serum creatinine/eGFR and potassium within 1-2 weeks after starting ACE inhibitors, ARBs, or diuretics 1, 6
• Continue monitoring at least annually 1
• Monitor for orthostatic hypotension, especially when initiating combination therapy 1

Common Pitfalls to Avoid

1. Underutilization of thiazide diuretics despite strong evidence supporting their efficacy and ability to reduce cardiovascular events 1, 7

2. Inappropriate monotherapy with low-dose HCTZ (12.5 mg) - Standard hydrochlorothiazide at this dose may convert sustained hypertension to masked hypertension due to its short duration of action 2

3. Combination of ACE inhibitors and ARBs should be avoided due to increased risk of adverse events (hyperkalemia, syncope, acute kidney injury) without added cardiovascular benefit 1

4. Inadequate dose titration - Most patients will require dose adjustments or additional medications to achieve target BP 1, 8

5. Failure to consider bedtime dosing - Evening dosing of antihypertensive medications may provide better blood pressure control 1

Special Populations

• Black patients: Thiazide diuretics or calcium channel blockers are more effective as initial therapy 1

• Elderly patients: Start with lower doses and titrate more cautiously to avoid orthostatic hypotension 6

• Patients with possible volume depletion (e.g., on diuretic therapy): Start with lower doses of ACE inhibitors (lisinopril 5 mg) 3 or ARBs (losartan 25 mg) 4

In summary, thiazide-type diuretics remain the cornerstone of initial hypertension therapy for most patients, with specific agents like ACE inhibitors or ARBs preferred in those with compelling indications such as diabetes, chronic kidney disease, or albuminuria.