Initial Pharmacological Treatment Protocol for Hypertension
First-line pharmacological treatment for hypertension should include thiazide diuretics, calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), or angiotensin receptor blockers (ARBs), with combination therapy often required to achieve blood pressure targets. 1
Initial Treatment Strategy Based on Blood Pressure Severity
For BP 140-159/90-99 mmHg (Stage 1 Hypertension):
- Start with a single antihypertensive medication from one of the first-line classes:
- Thiazide or thiazide-like diuretics (chlorthalidone preferred over hydrochlorothiazide)
- Long-acting dihydropyridine CCBs (e.g., amlodipine)
- ACEIs (e.g., lisinopril starting at 10 mg daily)
- ARBs (e.g., losartan starting at 50 mg daily)
For BP ≥160/100 mmHg (Stage 2 Hypertension):
- Initiate treatment with two antihypertensive medications from different classes 1
- Preferably use a single-pill combination to improve adherence 1
- Recommended combinations:
- ACEI or ARB + thiazide diuretic
- ACEI or ARB + CCB
- CCB + thiazide diuretic
Specific First-Line Medication Recommendations
Thiazide Diuretics:
- Chlorthalidone is preferred over hydrochlorothiazide due to superior efficacy and cardiovascular outcomes 1, 2
- Typical starting dose: 12.5 mg daily, may increase to 25 mg daily
- Monitor for electrolyte abnormalities, especially hypokalemia
ACE Inhibitors:
- Example: Lisinopril
- Starting dose: 10 mg once daily 3
- Usual maintenance dose: 20-40 mg daily 3
- Monitor for cough, angioedema, and hyperkalemia
Angiotensin Receptor Blockers:
- Example: Losartan
- Starting dose: 50 mg once daily 4
- Maximum dose: 100 mg once daily 4
- Use 25 mg starting dose in patients on diuretics or with possible volume depletion 4
Calcium Channel Blockers:
- Dihydropyridine CCBs (e.g., amlodipine)
- Starting dose: 5 mg once daily
- Maximum dose: 10 mg once daily
- Monitor for peripheral edema
Population-Specific Considerations
Black Patients:
- Thiazide diuretics or CCBs are preferred as initial therapy 1, 5
- ACEIs and ARBs are less effective in this population 1
Patients with Diabetes or Chronic Kidney Disease:
- ACEI or ARB is recommended as first-line therapy 1
- For patients with albuminuria (UACR ≥30 mg/g), ACEI or ARB is strongly recommended 1
- Target BP <130/80 mmHg 1
Elderly Patients (≥65 years):
- Target systolic BP <130 mmHg if tolerated 5
- Start with lower doses and titrate more gradually
- Be vigilant for orthostatic hypotension
Monitoring and Follow-up
- Check serum creatinine, estimated GFR, and potassium within 2-4 weeks of starting ACEIs, ARBs, or diuretics 1
- Monitor these parameters at least annually thereafter 1
- Follow up monthly after initiation or change in medication until target BP is reached 1
- Once BP is controlled, follow up every 3-5 months 1
Treatment of Resistant Hypertension
- Defined as BP ≥140/90 mmHg despite three antihypertensive medications including a diuretic 1
- Consider adding a mineralocorticoid receptor antagonist (spironolactone) 1
- Evaluate for medication adherence, white coat hypertension, and secondary causes of hypertension
Common Pitfalls to Avoid
Inappropriate combinations: Avoid combining ACEIs with ARBs or direct renin inhibitors due to increased risk of hyperkalemia, syncope, and acute kidney injury 1
Inadequate dosing: Many patients require maximum doses of medications to achieve BP targets
Clinical inertia: Don't delay adding a second or third medication when BP remains above target
Ignoring lifestyle modifications: Emphasize weight loss, DASH diet, sodium restriction, physical activity, and alcohol moderation alongside pharmacological therapy 5
Overlooking comorbidities: Tailor medication choices to patient-specific conditions (e.g., heart failure, coronary artery disease)
By following this protocol and selecting appropriate medications based on patient characteristics and comorbidities, clinicians can effectively manage hypertension and reduce the risk of cardiovascular morbidity and mortality.