What is the recommended initial treatment for hypertension?

Initial Treatment for Hypertension

The recommended initial treatment for hypertension is a thiazide or thiazide-like diuretic, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), or calcium channel blocker (CCB), with combination therapy recommended for most patients with confirmed hypertension (BP ≥140/90 mmHg). 1

First-Line Medication Options

Single-Agent Therapy

For patients with stage 1 hypertension and BP goal <130/80 mmHg, initiation with a single antihypertensive drug is reasonable, with dosage titration and sequential addition of other agents to achieve the BP target 1. The four major drug classes with proven efficacy include:

• Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide)
• ACE inhibitors (e.g., lisinopril)
• ARBs (when ACE inhibitors are not tolerated)
• Calcium channel blockers (dihydropyridine type)

Combination Therapy

For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment 1. For stage 2 hypertension with BP >20/10 mmHg above target, initiation with two first-line agents of different classes is strongly recommended 1, 2.

Preferred combinations include:

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine CCB
• RAS blocker (ACE inhibitor or ARB) + thiazide/thiazide-like diuretic

Patient-Specific Considerations

Race/Ethnicity Considerations

• Black patients: Initial therapy should include a thiazide-type diuretic or CCB 1
• Non-Black patients: Any of the four major drug classes can be used

Comorbidity Considerations

• Diabetes: ACE inhibitors or ARBs preferred, especially with albuminuria 2
• Heart failure: ACE inhibitors, ARBs, or beta-blockers 2
• CKD: ACE inhibitors to slow kidney disease progression 2
• Elderly patients (≥65 years): More gradual dose titration with careful monitoring for orthostatic hypotension 2

Medication Selection Details

Thiazide Diuretics

• Chlorthalidone is preferred over hydrochlorothiazide due to longer half-life and stronger evidence in landmark clinical trials 1
• Starting dose: 25 mg once daily 3
• May increase to 50 mg if response is insufficient 3

ACE Inhibitors

• Lisinopril starting dose: 10 mg once daily 4
• Usual dosage range: 20-40 mg per day 4
• For patients already on diuretics, start with 5 mg once daily 4

Treatment Algorithm

1. Assess hypertension severity:

   • Stage 1 (130-139/80-89 mmHg): Consider single-agent therapy
   • Stage 2 (≥140/90 mmHg): Use combination therapy

2. Select initial therapy based on patient characteristics:

   • Black patients: Thiazide diuretic or CCB
   • Diabetes/CKD with albuminuria: ACE inhibitor or ARB
   • Most other patients: Any of the four major classes or combination

3. Monitor and titrate:

   • Check BP within 2-4 weeks of starting therapy 2
   • Monitor electrolytes and renal function within 2-4 weeks when starting diuretics or RAS blockers 2
   • Titrate dose or add additional agents if BP remains above target

4. If BP remains uncontrolled on 2-drug therapy:

   • Add a third drug (typically RAS blocker + CCB + thiazide diuretic) 1
   • Consider single-pill combinations to improve adherence 1, 2

Common Pitfalls to Avoid

• Inappropriate combinations: Never combine two RAS blockers (ACE inhibitor + ARB) due to increased adverse effects without additional benefit 1, 2
• Overlooking lifestyle modifications: Diet, exercise, and sodium restriction should accompany pharmacological therapy 2, 5
• Therapeutic inertia: Don't delay intensifying treatment when BP remains uncontrolled 2
• Drug interactions: Be aware of interactions with NSAIDs, decongestants, and certain supplements 2

Target Blood Pressure

• General target: <130/80 mmHg 1
• For older adults (≥65 years): SBP <130 mmHg if tolerated 1
• For frail elderly or those with limited life expectancy: Consider less aggressive targets based on clinical judgment and patient preference 1

Remember that an SBP reduction of 10 mmHg decreases risk of cardiovascular disease events by approximately 20-30% 5, highlighting the importance of achieving and maintaining target blood pressure.