What is the drug of choice for a 55-year-old male with hypertension?

First-Line Antihypertensive Treatment for a 55-Year-Old Male

For a 55-year-old male with hypertension, a thiazide diuretic is the recommended first-line treatment based on the most recent and highest quality evidence. 1

Treatment Selection Algorithm

Step 1: Assess Initial Medication Choice

• First-line options (in order of preference):
  1. Thiazide or thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide)
  2. Angiotensin-converting enzyme inhibitor (ACEI)
  3. Angiotensin receptor blocker (ARB)
  4. Calcium channel blocker (CCB)

Step 2: Consider Patient-Specific Factors

• For a 55-year-old male with no specified comorbidities:
  • Thiazide diuretics have demonstrated superiority in preventing cardiovascular disease events 2
  • NICE guidelines specifically recommend ACEIs or ARBs for patients under 55 years, but this patient is 55 3
  • For patients ≥55 years, CCBs or thiazide diuretics are typically preferred 3

Step 3: Dosing and Monitoring

• Start with a low dose of the selected medication
• Reassess BP within 2-4 weeks after starting treatment 1
• Target BP goal: <130/80 mmHg 1
• Monitor serum potassium and renal function, especially with thiazides, ACEIs, or ARBs 1

Evidence Supporting Thiazide Diuretics

Thiazide diuretics have the strongest evidence base for first-line treatment:

1. Mortality reduction: Only low-dose thiazide diuretics and ACEIs have been shown to reduce all-cause mortality in hypertensive patients compared to placebo 4

2. Cardiovascular outcomes: The ALLHAT trial (33,357 participants) demonstrated that chlorthalidone was superior to amlodipine in preventing heart failure and superior to lisinopril in preventing stroke 2

3. Cost-effectiveness: Thiazide diuretics are less expensive than other antihypertensive medications while being equally or more effective 2

4. Guidelines consensus: Multiple guidelines, including the American College of Cardiology and AHA/ACC/CDC, recommend thiazide diuretics as a first-line option 3, 1

Alternative Options

If thiazide diuretics are contraindicated or not tolerated:

• ACE inhibitors like lisinopril are appropriate alternatives, particularly for patients with certain comorbidities such as diabetes or chronic kidney disease 5

• ARBs like losartan may be considered if ACEIs cause cough 6

• CCBs are another viable alternative, particularly for black patients or those with isolated systolic hypertension 3

Common Pitfalls to Avoid

1. Inadequate dosing: Start with at least half the maximum recommended dose to minimize the need for multiple up-titrations 3

2. Inappropriate combinations: Avoid combining two RAS blockers (ACEI + ARB) as this increases adverse effects without significant blood pressure benefit 1

3. Delayed follow-up: Ensure follow-up within 2-4 weeks after medication changes to assess efficacy and side effects 1

4. Ignoring lifestyle modifications: Dietary changes (DASH diet, sodium restriction), weight management, and physical activity should accompany pharmacological therapy 1, 7

5. Suboptimal BP control: Only 44% of US adults with hypertension have their BP controlled to <140/90 mmHg 7

By following this approach and starting with a thiazide diuretic, you can provide evidence-based care that optimizes cardiovascular outcomes for this 55-year-old male with hypertension.