What is the initial treatment approach for hypertension in a new intern in India?

Initial Hypertension Treatment Approach for New Interns in India

For new interns in India, the initial treatment of hypertension should begin with a thiazide-like diuretic plus calcium channel blocker (CCB) or CCB plus angiotensin receptor blocker (ARB) as a single pill combination, particularly for patients of South Asian descent. 1

Diagnosis and Assessment

• Use validated BP measuring device with appropriate cuff size
• Take the average of 2 readings
• Confirm hypertension with repeated office BP ≥140/90 mmHg
• Consider home BP monitoring (≥135/85 mmHg indicates hypertension) or 24-hour ambulatory BP monitoring (≥130/80 mmHg indicates hypertension) 1

Hypertension Classification

Category	Systolic BP	Diastolic BP
Normal BP	<130 mmHg	<85 mmHg
High-normal BP	130-139 mmHg	85-89 mmHg
Grade 1 Hypertension	140-159 mmHg	90-99 mmHg
Grade 2 Hypertension	≥160 mmHg	≥100 mmHg

Initial Treatment Approach

Non-Pharmacological Interventions (First-line for all patients)

1. Dietary modifications:

   • Salt restriction (major focus for South Asian populations) 1, 2
   • Increased potassium intake (fruits and vegetables) 2, 3
   • Reduced alcohol consumption 3
   • Healthy dietary pattern 2, 3

2. Physical activity: Regular exercise appropriate to patient's condition 2, 3

3. Weight management: For overweight/obese patients 2, 4

4. Tobacco cessation: For smokers 2, 4

5. Stress management: Particularly important in the Indian context 2, 3

Pharmacological Treatment

When to Start Medications:

• Immediate initiation for:
  • Grade 2 hypertension (≥160/100 mmHg)
  • Grade 1 hypertension with high-risk factors (CVD, CKD, diabetes, organ damage)
  • Persistent Grade 1 hypertension after 3-6 months of lifestyle modifications 1

First-line Medication Algorithm for South Asian Patients:

1. For patients <55 years:

   • Start with low-dose ACE inhibitor (e.g., enalapril 5 mg daily) or ARB (e.g., losartan 50 mg daily) 1, 5, 6
   • If BP not controlled, increase to full dose
   • Add thiazide/thiazide-like diuretic if needed

2. For patients ≥55 years or Black patients:

   • Start with low-dose ARB + dihydropyridine CCB or CCB + thiazide-like diuretic as single pill combination 1
   • If BP not controlled, increase to full dose
   • Add diuretic or ACE inhibitor/ARB if needed

Special Considerations for ACE Inhibitors:

• If starting enalapril in patients on diuretics:
  • Discontinue diuretic 2-3 days before starting if possible
  • If diuretic cannot be discontinued, start with lower dose (2.5 mg) under medical supervision 5
  • Monitor for hypotension for at least two hours after first dose 5

Medication Titration:

• Adjust dosage according to BP response
• Usual dosage range for enalapril: 10-40 mg per day (single dose or divided) 5
• For losartan: typically 50-100 mg daily 6
• Target: Reduce BP to <130/80 mmHg 1
• Achieve target within 3 months 1

Implementation in Indian Context

• Utilize the India Hypertension Control Initiative (IHCI) framework where available 7
• Consider using the Simple mobile application for record-keeping and follow-ups 7
• Ensure availability of essential medications as per local formulary
• Focus on patient education about medication adherence and lifestyle modifications 7

Monitoring and Follow-up

• Check BP within 1-2 weeks of starting or adjusting medication
• Monitor for adverse effects, particularly orthostatic hypotension
• Once BP is controlled, schedule regular follow-up visits
• Continue lifestyle modifications even after starting medications 4, 3

Common Pitfalls to Avoid

1. Neglecting lifestyle modifications: These should be emphasized even when medications are prescribed 4
2. Inadequate dosing: Don't hesitate to titrate medications to achieve target BP
3. Poor medication adherence: Use once-daily dosing when possible to improve compliance
4. Ignoring ethnic considerations: South Asian populations may have different responses to certain medications 1
5. Failure to consider comorbidities: Adjust treatment approach based on concurrent conditions

By following this structured approach, new interns in India can effectively manage hypertension in their patients, focusing on both non-pharmacological and pharmacological interventions to reduce cardiovascular risk.