What medications should be prescribed for new hypertension?

First-Line Medication Selection for New Hypertension

For newly diagnosed hypertension, first-line therapy should include an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), a calcium channel blocker (CCB), or a thiazide diuretic, with combination therapy often required to achieve blood pressure targets. 1, 2

Initial Treatment Algorithm

Step 1: Lifestyle Modifications

• Implement sodium restriction, DASH diet, regular physical activity, weight management
• Limit alcohol consumption and eliminate smoking
• Sugar restriction (<10% of energy intake)
• Allow maximum 3 months of lifestyle modifications alone for Stage 1 hypertension before adding medications 1

Step 2: Pharmacological Therapy Selection

1. First-line options (choose based on patient characteristics):

   • ACE inhibitors (e.g., lisinopril) or ARBs 1, 3
   • Calcium channel blockers (dihydropyridines like amlodipine) 1, 2
   • Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide, chlorthalidone) 2

2. Specific patient considerations:

   • Patients with elevated diastolic BP: ACE inhibitors/ARBs preferred 1
   • Black patients: CCBs or thiazide diuretics may be more effective 3
   • Patients with diabetes or CKD: ACE inhibitors/ARBs preferred 1
   • Patients with thoracic aortic disease: Consider beta-blockers 1

Step 3: Combination Therapy

• If BP remains uncontrolled on monotherapy, add a second agent from a different class
• Most effective combination: ACE inhibitor/ARB + CCB 1
• Consider single-pill combinations to improve adherence 4

Step 4: Triple Therapy

• If BP remains uncontrolled on dual therapy, add a thiazide diuretic
• Triple combination: ACE inhibitor/ARB + CCB + thiazide diuretic 1

Step 5: Resistant Hypertension

• Add spironolactone or beta-blocker as fourth-line agent 1

Target Blood Pressure Goals

• General adult population: <130/80 mmHg 1, 2
• Older adults (≥65 years): 130-139/70-79 mmHg 1
• Very elderly (≥85 years) or frail: <140/90 mmHg 1
• Patients with diabetes or CKD: <130/80 mmHg 1

Monitoring and Safety Considerations

• Check blood pressure and renal function within 1-2 weeks after initiating or changing medications 1
• Monitor for orthostatic hypotension, especially in elderly patients 1
• For ACE inhibitors/ARBs:
  • Monitor renal function and potassium levels 1
  • Watch for cough with ACE inhibitors (consider switching to ARB if occurs)
• For thiazide diuretics:
  • Avoid if CrCl <30 mL/min 1
  • Monitor electrolytes, particularly potassium
• For spironolactone:
  • Use cautiously with creatinine >2.5 mg/dL 1
  • Monitor potassium closely, especially when combined with ACE/ARBs 1

Clinical Pearls and Pitfalls

• Don't delay treatment: Uncontrolled hypertension significantly increases cardiovascular risk 2, 5
• Avoid rapid BP reduction: In non-emergency situations, gradually lower BP to prevent organ hypoperfusion
• Don't discontinue medications: Unless clinically indicated, as this can worsen BP control and increase cardiovascular risk 1
• Avoid hydralazine and immediate-release nifedipine: These can cause unpredictable BP drops 6
• Consider home BP monitoring: To confirm diagnosis and monitor treatment effectiveness 4

Special Considerations for Lisinopril

Lisinopril is an effective ACE inhibitor for hypertension with these characteristics:

• Once-daily dosing (24-hour effect)
• Starting dose typically 10 mg daily (range 20-40 mg/day)
• Lower doses needed in elderly, renal impairment, or heart failure patients
• No hepatic metabolism required (beneficial in liver disease)
• Eliminated primarily by kidneys (dose adjustment needed in renal impairment)
• Can be used alone or with other antihypertensives 3, 7