What is the management approach for first-time diagnosed Hypertension (HTN), including medication names, doses, potential interactions, and treatment complications?

Management of First-Time Diagnosed Hypertension

For first-time diagnosed hypertension, initial treatment should include lifestyle modifications and pharmacological therapy with an ACE inhibitor, ARB, thiazide-like diuretic, or dihydropyridine calcium channel blocker, with medication selection based on patient characteristics. 1, 2

Classification and Diagnosis

Hypertension is classified as:

• Normal BP: <120/80 mmHg
• Elevated BP: 120-129/<80 mmHg
• Stage 1 Hypertension: 130-139/80-89 mmHg
• Stage 2 Hypertension: ≥140/≥90 mmHg 2

Diagnosis should be confirmed with multiple office blood pressure measurements and consideration of ambulatory or home blood pressure monitoring to rule out white-coat hypertension.

Lifestyle Modifications

Lifestyle modifications are essential for all hypertensive patients:

• Weight management: Achieve and maintain healthy BMI (18.5-24.9 kg/m²) 1, 2
• Dietary approach: Follow DASH diet with increased fruits, vegetables, low-fat dairy, and reduced saturated fat 1
• Sodium restriction: Limit to <2,300 mg/day 1
• Potassium intake: Increase consumption (8-10 servings of fruits/vegetables per day) 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 1
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
• Smoking cessation: Complete cessation recommended 2

Pharmacological Management

Initial Drug Selection

1. Blood pressure 130/80-150/90 mmHg: Start with a single drug 1
2. Blood pressure ≥150/90 mmHg: Start with two antihypertensive medications 1

First-line Medication Options:

• ACE inhibitors (e.g., lisinopril): Starting dose 5-10 mg daily, can be titrated up to 40 mg daily 3
• ARBs (e.g., losartan): Starting dose 25-50 mg daily, can be titrated up to 100 mg daily 4
• Thiazide-like diuretics (e.g., chlorthalidone, indapamide): Preferred over hydrochlorothiazide due to longer duration of action 1, 2
• Dihydropyridine calcium channel blockers (e.g., amlodipine): Starting dose 2.5-5 mg daily, can be titrated up to 10 mg daily 5

Patient-Specific Considerations:

• Patients with albuminuria (UACR ≥30 mg/g): Start with ACE inhibitor or ARB 1
• Patients with coronary artery disease: ACE inhibitor or ARB preferred 1
• Black patients: Calcium channel blocker or thiazide-like diuretic preferred as initial therapy 2
• Pregnant women or women of childbearing potential: Avoid ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors 1

Monitoring and Follow-up

• Check blood pressure within 1-2 weeks of starting or adjusting medication 2
• Monitor serum creatinine and potassium 7-14 days after initiation of ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1
• Monitor for hypokalemia when diuretics are used 1
• Aim to achieve target blood pressure within 3 months 2
• Target blood pressure is generally <130/80 mmHg 2, 6

Treatment Algorithm

1. Start with lifestyle modifications for all patients
2. Assess BP severity:
   • If BP 130/80-150/90 mmHg: Start single agent
   • If BP ≥150/90 mmHg: Start two agents
3. Select appropriate medication(s) based on:
   • Presence of albuminuria → ACE inhibitor/ARB
   • Coronary artery disease → ACE inhibitor/ARB
   • Black race → CCB or thiazide-like diuretic
   • No specific indications → Any first-line agent
4. Monitor response within 1-2 weeks
5. Adjust therapy if target BP not achieved:
   • Increase dose of initial medication
   • Add second agent from a different class
6. For resistant hypertension (BP uncontrolled on 3 medications including a diuretic), consider adding a mineralocorticoid receptor antagonist 1

Potential Complications and Contraindications

• ACE inhibitors/ARBs: Hyperkalemia, acute kidney injury, angioedema; contraindicated in pregnancy 1
• Calcium channel blockers: Peripheral edema, headache, flushing 5
• Thiazide diuretics: Hypokalemia, hyperuricemia, hyperglycemia 2
• Common pitfalls: Delayed treatment, inadequate monitoring, medication non-adherence, overlooking secondary causes of hypertension 2

Improving Adherence

• Use once-daily dosing regimens when possible 2
• Consider single-pill combinations to improve adherence 1, 2
• Regular follow-up to assess medication adherence and efficacy 2
• Educate patients about the importance of both medication and lifestyle modifications 7

By following this comprehensive approach to hypertension management, clinicians can effectively reduce cardiovascular risk and prevent complications associated with uncontrolled hypertension.