What is the initial pharmacological approach for managing hypertension?

Initial Pharmacological Therapy for Hypertension Management

For initial pharmacological management of hypertension, first-line agents include thiazide diuretics, calcium channel blockers (CCBs), angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs). 1, 2

Initial Approach Based on Hypertension Severity

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

• Begin with a single antihypertensive medication 1
• Recommended starting doses:
  • ACE inhibitors: Lisinopril 10 mg daily 3
  • ARBs: Losartan 50 mg daily 4
  • Thiazide diuretics: Hydrochlorothiazide 12.5-25 mg daily or chlorthalidone (preferred)
  • CCBs: Amlodipine 5 mg daily

Stage 2 Hypertension (≥160/100 mmHg)

• Begin with two antihypertensive medications from different classes 1, 2
• Common effective combinations:
  • ACE inhibitor + thiazide diuretic
  • ARB + thiazide diuretic
  • CCB + ACE inhibitor/ARB

Patient-Specific Considerations

For Patients with Diabetes

• ACE inhibitors or ARBs are preferred first-line agents 1, 2
• For patients with albuminuria (UACR ≥30 mg/g creatinine), an ACE inhibitor or ARB is strongly recommended 1

For Patients with Chronic Kidney Disease

• ACE inhibitors or ARBs are preferred first-line agents 2
• For patients with albuminuria (UACR ≥300 mg/g), ACE inhibitors or ARBs at maximum tolerated dose are strongly recommended 1

For Black Patients

• CCBs or thiazide diuretics are more effective as initial therapy than ACE inhibitors 1, 2
• ARBs may be better tolerated than ACE inhibitors in black patients (less cough and angioedema) 1

For Elderly Patients

• Start with lower doses and titrate more gradually 2
• Monitor for orthostatic hypotension

Monitoring and Follow-up

1. After initiating therapy, follow up within 2-4 weeks to assess response and adjust medication as needed 2
2. For patients on ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium levels within 2-4 weeks of initiation and at least annually thereafter 1, 2
3. Once target BP is achieved, follow up every 3-5 months 2

Management of Resistant Hypertension

If BP remains uncontrolled on three antihypertensive medications (including a diuretic):

• Consider adding a mineralocorticoid receptor antagonist (e.g., spironolactone 25 mg daily) 1
• Refer to a specialist with expertise in BP management 1

Common Pitfalls to Avoid

1. Therapeutic inertia: Failing to intensify treatment when BP remains uncontrolled 2
2. Ignoring drug interactions: NSAIDs, decongestants, and certain supplements can interfere with BP control 2
3. Inadequate dosing: Using suboptimal doses of medications, particularly ACE inhibitors 5
4. Inappropriate combinations: Combining ACE inhibitors with ARBs or direct renin inhibitors increases adverse effects without additional benefit 1
5. Overlooking lifestyle modifications: Diet, exercise, and sodium restriction should accompany pharmacological therapy 1, 2

By following these evidence-based recommendations for initial pharmacological therapy, clinicians can effectively manage hypertension and reduce the risk of cardiovascular events, stroke, and mortality in their patients.