What is the initial medication for managing hypertension?

Initial Medication for Managing Hypertension

Thiazide-type diuretics should be used as initial therapy for most patients with uncomplicated hypertension, either alone or in combination with another agent such as an ACE inhibitor or beta blocker. 1

First-Line Medication Selection

The choice of initial antihypertensive medication depends on several factors:

For Uncomplicated Hypertension:

• Thiazide-type diuretics (e.g., hydrochlorothiazide) are the recommended first-line therapy for most patients 1
• Starting dose for hydrochlorothiazide is typically one capsule (12.5-25mg) once daily 2

For Specific Patient Populations:

• Patients with diabetes or chronic kidney disease with albuminuria: ACE inhibitors (e.g., lisinopril) or ARBs are preferred first-line agents 1
• Patients with heart failure: ACE inhibitors are recommended 1
• Black patients: Calcium channel blockers or diuretics may be more effective than ACE inhibitors or beta-blockers 3

Dosing Considerations

• Lisinopril (ACE inhibitor): Initial dose is 10mg once daily, with usual dosage range of 20-40mg per day; if used with diuretics, start at 5mg once daily 4
• Amlodipine (Calcium channel blocker): Initial dose is 5mg once daily, maximum 10mg once daily; elderly or hepatically impaired patients should start at 2.5mg 5
• Hydrochlorothiazide: One capsule once daily, with total daily doses not exceeding 50mg 2

Treatment Algorithm Based on Blood Pressure Severity

1. Stage 1 Hypertension (140-159/90-99 mmHg):

   • Start with thiazide-type diuretic for most patients
   • May consider ACE inhibitor, ARB, beta-blocker, or calcium channel blocker based on comorbidities 1

2. Stage 2 Hypertension (≥160/100 mmHg):

   • Begin with 2-drug combination (usually thiazide-type diuretic plus ACE inhibitor, ARB, beta-blocker, or calcium channel blocker) 1
   • This approach is more likely to achieve blood pressure control quickly 1

Special Considerations

• Compelling indications may dictate specific drug choices:

  • Heart failure: ACE inhibitors
  • Post-myocardial infarction: Beta-blockers
  • Diabetes: ACE inhibitors or ARBs
  • Chronic kidney disease: ACE inhibitors or ARBs 1

• Blood pressure targets:

  • General population: <140/90 mmHg
  • Patients with diabetes or chronic kidney disease: <130/80 mmHg 1

Common Pitfalls to Avoid

1. Underutilization of diuretics: Despite evidence supporting their use, thiazide diuretics remain underused as first-line agents 1

2. Inadequate dosing: Many patients require dose adjustments or additional medications to reach target blood pressure

3. Ignoring compelling indications: Failing to consider comorbidities when selecting initial therapy

4. Delayed combination therapy: For patients with Stage 2 hypertension, starting with a single agent may delay achievement of blood pressure control 1

5. Overlooking medication adherence: Effective therapy controls hypertension only if the patient is motivated to take the medication 1

By following these evidence-based recommendations, clinicians can effectively initiate antihypertensive therapy to reduce cardiovascular and renal morbidity and mortality in patients with hypertension.