What are the initial treatment options for hypertension?

Initial Treatment Options for Hypertension

The initial treatment for hypertension should include lifestyle modifications for all patients with blood pressure >120/80 mmHg, with pharmacologic therapy added based on blood pressure severity, with ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers as first-line medication options. 1

Lifestyle Modifications

Lifestyle modifications are the foundation of hypertension management and should be implemented for all patients with blood pressure >120/80 mmHg:

• Weight loss when indicated (for overweight/obese patients)
• DASH diet (Dietary Approaches to Stop Hypertension)
  • Reduced sodium intake (<2,300 mg/day)
  • Increased potassium intake (8-10 servings of fruits and vegetables daily)
  • Low-fat dairy products (2-3 servings daily)
• Moderate alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women)
• Smoking cessation
• Regular physical activity (at least 150 minutes of moderate-intensity exercise weekly) 1, 2

These lifestyle interventions can lower blood pressure, enhance medication effectiveness, and promote overall cardiovascular health with minimal adverse effects 1.

Pharmacologic Therapy Algorithm

Step 1: Determine BP Severity and Initial Medication Approach

• BP 130/80-150/90 mmHg: Begin with a single antihypertensive agent
• BP ≥150/90 mmHg: Begin with two antihypertensive medications 1

Step 2: Select First-Line Medication(s)

First-line medications include:

1. ACE inhibitors (e.g., lisinopril)
2. ARBs (e.g., losartan)
3. Thiazide-like diuretics (e.g., chlorthalidone, indapamide)
4. Dihydropyridine calcium channel blockers (e.g., amlodipine) 1, 2

Step 3: Consider Patient-Specific Factors

• Black patients: Calcium channel blockers or thiazide-like diuretics preferred as initial therapy 2
• Non-Black patients: ACE inhibitors or ARBs often preferred as initial therapy 2, 3
• Patients with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB recommended 1
• Patients with coronary artery disease: ACE inhibitor or ARB recommended 1

Medication Dosing and Titration

• Lisinopril: Start at 10 mg once daily, titrate to 20-40 mg daily as needed 3
• Losartan: Start at 50 mg once daily, titrate to maximum 100 mg daily as needed 4
• Amlodipine: Start at 5 mg once daily, titrate to maximum 10 mg daily as needed 2
• Thiazide-like diuretics: Chlorthalidone and indapamide preferred over hydrochlorothiazide 1, 2

Monitoring and Follow-Up

• Monitor serum creatinine and potassium levels when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists
• Check for hypokalemia when using diuretics
• Laboratory monitoring should occur 7-14 days after initiation or dose changes 1
• Single-pill combinations may improve medication adherence 1, 2

Important Considerations and Cautions

• Pregnancy: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential who are not using reliable contraception 1

• Combination therapy: Never combine ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 2

• Elderly patients: Start at lower doses and titrate more gradually 2

• Resistant hypertension: Consider adding spironolactone if BP remains uncontrolled on three medications 2

The evidence strongly supports that lowering blood pressure reduces cardiovascular morbidity and mortality, with a 10 mmHg reduction in systolic BP decreasing cardiovascular event risk by approximately 20-30% 5. Despite available effective treatments, only 44% of US adults with hypertension have their blood pressure controlled to <140/90 mmHg 5, highlighting the importance of comprehensive management approaches.