What is the initial pharmacotherapy approach for treating hypertension?

Initial Pharmacotherapy Approach for Hypertension Treatment

The initial pharmacotherapy for hypertension should begin with an ACE inhibitor/ARB, thiazide-like diuretic, or calcium channel blocker for most patients, with combination therapy recommended for those with BP ≥160/100 mmHg. 1, 2

Step-by-Step Approach to Hypertension Medication Selection

Step 1: Assess Patient Characteristics

• Blood pressure level: Determine severity (≥160/100 mmHg warrants immediate combination therapy)
• Race/ethnicity: Different recommendations for Black vs. non-Black patients
• Comorbidities: Presence of diabetes, CKD, CAD, heart failure
• Risk factors: Age, target organ damage

Step 2: Initial Medication Selection

For Non-Black Patients:

1. First-line: Low dose ACE inhibitor or ARB (e.g., lisinopril 10 mg daily or losartan 50 mg daily) 1, 3, 4
2. Second-line: Add dihydropyridine calcium channel blocker (e.g., amlodipine)
3. Third-line: Add thiazide/thiazide-like diuretic (preferably chlorthalidone over hydrochlorothiazide)

For Black Patients:

1. First-line: Low dose ARB + dihydropyridine calcium channel blocker or dihydropyridine calcium channel blocker + thiazide-like diuretic 1, 2
2. Second-line: Increase to full dose
3. Third-line: Add diuretic or ACE inhibitor/ARB (whichever wasn't used initially)

Step 3: Special Considerations

• Diabetes with albuminuria: Start with ACE inhibitor or ARB 1
• Chronic kidney disease with proteinuria: ACE inhibitor or ARB 1
• Coronary artery disease: ACE inhibitor or ARB preferred 1
• Heart failure with reduced ejection fraction: Beta-blocker + ACE inhibitor/ARB 5
• Elderly patients (>80 years) or frail: Consider monotherapy with lower starting doses 1, 2

Medication Dosing and Titration

1. Start with appropriate dose based on patient characteristics:

   • Standard patients: Full recommended starting dose
   • Elderly/frail: Lower starting dose (e.g., lisinopril 5 mg instead of 10 mg) 3

2. Titration schedule:

   • Assess response after 2-4 weeks
   • If BP not at target, increase to full dose of initial medication
   • If still not at target after full dose, add second agent from a different class
   • Target should be achieved within 3 months 1

3. Resistant hypertension (BP ≥140/90 mmHg despite 3 medications including a diuretic):

   • Add spironolactone (mineralocorticoid receptor antagonist) 1
   • If not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Important Considerations and Pitfalls

• Do not combine ACE inhibitors with ARBs - this combination increases adverse effects without additional benefit 5
• Monitor renal function and potassium when using ACE inhibitors, ARBs, or diuretics 1
• Consider fixed-dose combinations to improve adherence, especially for patients requiring multiple medications 1, 2
• For BP ≥160/100 mmHg, initiate treatment with two agents rather than monotherapy for more rapid control 1, 6
• Avoid excessive lowering of diastolic BP below 70-75 mmHg in elderly patients with coronary heart disease 2

Treatment Targets

• General target: <130/80 mmHg 1
• Elderly (≥65 years): Systolic BP 130-139 mmHg 1, 2
• Very elderly (≥85 years) or frail: More lenient target (<140/90 mmHg) 2

By following this structured approach to hypertension pharmacotherapy, clinicians can effectively reduce cardiovascular morbidity and mortality while minimizing adverse effects. The key is selecting the appropriate initial medication based on patient characteristics and systematically adding medications if blood pressure targets are not achieved.