What is the recommended initial medication for a patient with new onset hypertension?

First-Line Medication for New Onset Hypertension

For patients with newly diagnosed hypertension, a thiazide-type diuretic is recommended as first-line therapy, either alone or in combination with other agents depending on blood pressure severity. 1, 2

Initial Medication Selection Algorithm

For uncomplicated hypertension:

1. First choice: Thiazide-type diuretic (preferably chlorthalidone over hydrochlorothiazide due to greater 24-hour blood pressure reduction and superior outcomes) 1

2. Alternative first-line options (if thiazide is contraindicated or not tolerated):

   • ACE inhibitor (e.g., lisinopril)
   • ARB (e.g., losartan)
   • Dihydropyridine calcium channel blocker (e.g., amlodipine)

For specific patient populations:

• Patients with albuminuria or diabetes: Start with ACE inhibitor or ARB 2
• Black patients: Thiazide diuretic or calcium channel blocker preferred 1
• Patients with chronic kidney disease: ACE inhibitor or ARB 1

Dosing and Titration

• Initial BP 140-159/90-99 mmHg: Start with a single agent
• Initial BP ≥160/100 mmHg: Start with two-drug combination (usually thiazide-type diuretic plus ACE inhibitor, ARB, or calcium channel blocker) 2

Medication-Specific Starting Doses

• Thiazide diuretics: Chlorthalidone 12.5-25 mg daily
• ACE inhibitors: Lisinopril 10 mg daily (5 mg if on diuretics) 3
• ARBs: Losartan 50 mg daily (25 mg if volume depleted) 4
• Calcium channel blockers: Amlodipine 5 mg daily

Follow-up and Monitoring

• Assess response in 2-4 weeks
• Monitor serum creatinine/eGFR and potassium levels at least annually for patients on ACE inhibitors, ARBs, or diuretics 2
• If BP goal not achieved, increase dose or add a second agent from a different class

Important Considerations and Pitfalls

1. Avoid these combinations:

   • ACE inhibitor + ARB (increased risk of renal dysfunction)
   • ACE inhibitor or ARB + direct renin inhibitor 2, 1

2. Medication adherence is crucial for effective BP control. Consider single-pill combinations when possible to improve adherence 1

3. Lifestyle modifications should always accompany pharmacologic therapy:

   • Sodium restriction (<2,300 mg/day)
   • DASH diet (fruits, vegetables, whole grains, low-fat dairy)
   • Regular physical activity (90-150 minutes/week)
   • Weight loss if overweight/obese
   • Alcohol moderation 2, 1

4. Common pitfall: Underutilization of diuretics despite strong evidence supporting their efficacy and affordability 2, 1

5. Special caution: Start with lower doses in elderly patients or those at risk for orthostatic hypotension 2

The evidence strongly supports thiazide-type diuretics as first-line therapy for most patients with uncomplicated hypertension, with the most recent guidelines emphasizing their efficacy, safety, and cost-effectiveness 1, 5, 6. While all major classes (thiazides, ACE inhibitors, ARBs, and calcium channel blockers) effectively lower blood pressure and reduce cardiovascular events, thiazides remain the preferred initial choice unless specific comorbidities indicate otherwise.