When restarting antihypertensive medications, which class of medications do you start with first?

Restarting Antihypertensive Medications: Which Class to Start First

When restarting blood pressure medications, thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers should be used as first-line agents, with selection based on patient demographics and comorbidities. 1

General Approach to Restarting Antihypertensives

The selection of which antihypertensive medication to restart first depends on several key factors:

Patient Demographics

• Age considerations:
  • For patients <55 years: ACE inhibitors or ARBs are preferred 1
  • For patients ≥55 years or Black patients: Calcium channel blockers (CCBs) or thiazide diuretics are preferred 1, 2

Comorbidity-Based Selection

Different comorbidities warrant specific first-line agents:

• Stroke/TIA history: Thiazide diuretics, ACE inhibitors, ARBs, or combination of thiazide + ACE inhibitor 1
• Chronic kidney disease: ACE inhibitors or ARBs, especially with albuminuria 1
• Diabetes: ACE inhibitors or ARBs if albuminuria is present 1
• Heart failure with reduced EF: Guideline-directed medical therapy beta blockers 1
• Coronary artery disease: Beta blockers, ACE inhibitors, or ARBs 1

Specific Restart Protocols

Post-Stroke Patients

For patients with previous stroke or TIA:

1. Restart antihypertensive treatment within the first few days after the event 1
2. First-line options include thiazide diuretics, ACE inhibitors, or ARBs 1
3. Target BP goal of <130/80 mmHg may be reasonable 1

Common Pitfalls to Avoid

• Avoid simultaneous use of ACE inhibitors, ARBs, and/or renin inhibitors as this combination is potentially harmful 1
• Avoid assuming thiazide diuretics are ineffective in advanced CKD; they can still be effective even with eGFR <30 mL/min/1.73 m² 1
• Don't delay restarting medications after stroke; evidence supports restarting antihypertensives after the first few days of the index event 1

Algorithm for Restarting Antihypertensive Medications

1. Assess patient characteristics:

   • Age, race, comorbidities
   • Previous BP medication history and response

2. Select first-line agent based on:

   • For Black patients: Start with thiazide diuretic or CCB 2
   • For patients with stroke history: Thiazide diuretic, ACE inhibitor, or ARB 1
   • For patients with CKD or diabetes with albuminuria: ACE inhibitor or ARB 1
   • For patients <55 years without comorbidities: ACE inhibitor or ARB 1
   • For patients ≥55 years without comorbidities: CCB or thiazide diuretic 1

3. Dosing considerations:

   • Start with at least half of the maximum recommended dose 1
   • For losartan, typical starting dose is 50 mg once daily (25 mg for those with possible intravascular depletion) 3

4. Monitoring and adjustment:

   • Review and modify dose every 2-4 weeks until BP is controlled 1
   • Consider adding a second agent from a complementary class if target BP is not achieved 1, 2

Evidence Quality and Consensus

The recommendations from various guidelines show some variation, reflecting the absence of conclusive clinical evidence demonstrating superiority of any specific drug class 1. The 2017 ACC/AHA guidelines provide the most recent comprehensive recommendations, suggesting thiazide diuretics, CCBs, ACE inhibitors, or ARBs as first-line agents 1.

While some guidelines (like AHA/ACC/CDC) recommend thiazide diuretics as first-line therapy, others (like French guidelines) recommend ACE inhibitors or ARBs due to improved persistence 1. This highlights the importance of considering individual patient factors when selecting which medication to restart first.