What is the recommended initial medication for treating hypertension?

First-Line Medication for Hypertension

Thiazide-type diuretics should be used as initial therapy for most patients with uncomplicated hypertension, alone or combined with drugs from other classes. 1

Initial Treatment Selection Algorithm

Step 1: Assess Patient's Blood Pressure and Risk Factors

• For BP between 140/90 mmHg and 159/99 mmHg: Begin with a single drug
• For BP ≥160/100 mmHg: Begin with two-drug combination therapy 1

Step 2: Select Initial Agent Based on Patient Characteristics

For Uncomplicated Hypertension:

• First choice: Thiazide-type diuretic (e.g., hydrochlorothiazide, chlorthalidone) 1, 2

For Specific Patient Populations:

• Diabetes with albuminuria: ACE inhibitor or ARB 1, 2
• Black patients: Diuretic or calcium channel blocker 2
• Chronic kidney disease: ACE inhibitor or ARB 1, 2
• Heart failure: Include beta-blocker and consider aldosterone antagonist 2

Rationale for Thiazide Diuretics as First-Line

1. Enhanced antihypertensive efficacy in multidrug regimens
2. Proven to reduce complications of hypertension in clinical trials
3. More affordable than other agents 1
4. Recommended by major guidelines including JNC 7 1

Alternative First-Line Options

Any of these drug classes have demonstrated cardiovascular event reduction in patients with diabetes:

• ACE inhibitors
• Angiotensin receptor blockers (ARBs)
• Thiazide-like diuretics
• Dihydropyridine calcium channel blockers 1

Combination Therapy Considerations

If BP is ≥20/10 mmHg above goal, consider initiating therapy with two agents:

• Preferred two-drug combinations include:
  • Thiazide diuretic + ACE inhibitor
  • Thiazide diuretic + ARB
  • Calcium antagonist + ACE inhibitor
  • Calcium antagonist + ARB
  • Calcium antagonist + thiazide diuretic 1, 2

Dosing Considerations

For ACE inhibitors like lisinopril:

• Initial dose: 10 mg once daily
• Usual dosage range: 20-40 mg per day
• If used with diuretics: Start at 5 mg once daily 3

Important Caveats

• Monitor serum creatinine/eGFR and potassium levels at least annually for patients on ACE inhibitors, ARBs, or diuretics 1
• Adjust dosing for patients with renal impairment 3
• For resistant hypertension (BP ≥140/90 mmHg despite three medications including a diuretic), consider adding a mineralocorticoid receptor antagonist 1, 2

Follow-up and Monitoring

• Monitor BP monthly until control is achieved 2
• Regular monitoring of renal function and electrolytes is essential, particularly when adjusting medications 2

The evidence strongly supports thiazide diuretics as first-line therapy for most patients with uncomplicated hypertension, with specific alternatives for patients with compelling indications such as diabetes with albuminuria or chronic kidney disease.