What are the recommended medications and doses for treating hypertension?

Recommended Medications and Doses for Treating Hypertension

First-line treatment for hypertension should include a thiazide-like diuretic (chlorthalidone 12.5-25.0 mg once daily or indapamide 1.5 mg modified-release once daily) in combination with either an ACE inhibitor, ARB, or calcium channel blocker. 1, 2

Initial Treatment Approach

Step 1: Initial Drug Selection

• For Stage 1 Hypertension (130-139/80-89 mmHg):

  • Single-agent therapy may be appropriate
  • Options include:
    • Thiazide-like diuretic: Chlorthalidone 12.5 mg daily (preferred over hydrochlorothiazide) 1
    • ACE inhibitor: Lisinopril 10 mg daily 3
    • ARB: Consider for Black patients instead of ACE inhibitors 1
    • Long-acting calcium channel blocker: Amlodipine 5 mg daily 2

• For Stage 2 Hypertension (≥140/90 mmHg):

  • Immediate initiation of combination therapy is recommended 2
  • Preferred combinations:
    • Thiazide-like diuretic + calcium channel blocker
    • ACE inhibitor/ARB + calcium channel blocker
    • ACE inhibitor/ARB + thiazide-like diuretic 1, 2

Step 2: Dosage Titration

• If blood pressure not controlled after 2-4 weeks, increase to target doses:
  • Chlorthalidone: Up to 25 mg daily 1
  • Lisinopril: 20-40 mg daily 3
  • Amlodipine: Up to 10 mg daily 2

Special Population Considerations

Black Patients

• Thiazide-like diuretic + calcium channel blocker is particularly effective 2
• ARBs preferred over ACE inhibitors (lower risk of angioedema) 1, 2

Patients with Diabetes

• ACE inhibitor or ARB recommended as first-line, especially with albuminuria 1
• Target blood pressure <130/80 mmHg 1

Elderly Patients (≥80 years)

• Start with lower doses and titrate more gradually 2
• Consider standing blood pressure when making treatment decisions 1
• Continue well-tolerated treatment when patients reach age 80 1

Chronic Kidney Disease

• ACE inhibitor or ARB recommended first-line with albuminuria 1
• Consider loop diuretics instead of thiazides if creatinine clearance <30 mL/min 2
• Monitor serum creatinine/eGFR and potassium levels at least annually 1

Step-wise Treatment Algorithm

Step 1: Initial Therapy

• Stage 1 Hypertension: Single agent from recommended classes
• Stage 2 Hypertension: Two-drug combination therapy

Step 2: If BP Not Controlled

• Optimize doses of initial medications
• Add a third agent from a different class 1

Step 3: Resistant Hypertension

• If BP remains uncontrolled on optimal doses of 3 drugs (including a diuretic):
  • Add low-dose spironolactone (25 mg daily) if serum potassium <4.6 mmol/L 1
  • Consider alpha-blocker or beta-blocker if spironolactone contraindicated 1
  • Seek specialist advice if BP remains uncontrolled on 4 drugs 1

Monitoring and Follow-up

• Check electrolytes and renal function 2-4 weeks after initiating therapy 2
• Monthly follow-up until target BP achieved, then every 3-6 months 1, 2
• Home BP monitoring recommended to guide treatment adjustments 2

Important Considerations

Preferred Thiazide Diuretics

• Chlorthalidone has better evidence for cardiovascular outcomes than hydrochlorothiazide 1, 4, 5
• Low-dose thiazides (chlorthalidone 12.5-25 mg) provide effective BP reduction with fewer metabolic side effects 6

Combination Therapy Benefits

• Fixed-dose combinations improve adherence 2, 7
• Certain combinations (e.g., ACE inhibitor + calcium channel blocker) may have fewer adverse effects 7
• ACE inhibitor + thiazide combinations can offset each other's adverse effects (potassium balance) 8

Cautions

• Monitor potassium and renal function when using ACE inhibitors, ARBs, or diuretics 1
• Avoid combination of ACE inhibitor + ARB (increased risk of hyperkalemia and acute kidney injury) 1
• ACE inhibitors and ARBs are contraindicated in pregnancy 2

By following this evidence-based approach to hypertension management, clinicians can effectively reduce blood pressure and minimize cardiovascular risk in their patients.