What are the recommended treatment options for hypertension?

Treatment Options for Hypertension

Combination therapy with a renin-angiotensin system (RAS) blocker (ACE inhibitor or ARB), a calcium channel blocker (CCB), and a thiazide/thiazide-like diuretic is recommended as the core strategy for managing hypertension to reduce morbidity and mortality. 1

First-Line Treatment Approach

• For most patients with confirmed hypertension (BP ≥140/90 mmHg), initial therapy should include combination treatment with two first-line agents, preferably as a single-pill combination for better adherence 1
• The four major drug classes recommended as first-line treatments are:
  • ACE inhibitors (e.g., lisinopril)
  • ARBs (e.g., candesartan, valsartan)
  • Dihydropyridine CCBs (e.g., amlodipine)
  • Thiazide or thiazide-like diuretics (e.g., chlorthalidone, indapamide) 1
• Preferred initial combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine CCB or a thiazide/thiazide-like diuretic 1
• Single-pill combinations are strongly preferred over separate pills to improve adherence and persistence 1

Special Population Considerations

• For Black patients, initial treatment should include a diuretic or CCB, either alone or in combination with a RAS blocker 1
• For elderly patients (≥65 years), treatment may need to be initiated more gradually with consideration of frailty and comorbidities 1
• For patients with diabetes or chronic kidney disease (CKD) with proteinuria, a RAS blocker should be included in the regimen 1, 2
• For patients with heart failure with reduced ejection fraction (HFrEF), treatment should include an ACE inhibitor or ARB, a beta-blocker, and if needed, a mineralocorticoid receptor antagonist (MRA) 1

Blood Pressure Targets

• For most adults <65 years: target BP <130/80 mmHg 1, 2
• For adults ≥65 years: target systolic BP 120-130 mmHg if tolerated 1
• For patients with CKD and eGFR >30 mL/min/1.73m²: target systolic BP 120-129 mmHg 1
• For patients with diabetes: target BP <130/80 mmHg 1, 2

Step-by-Step Treatment Algorithm

1. Initial Assessment: Confirm hypertension diagnosis with office and out-of-office measurements 1
2. Step 1: Start with two-drug combination (RAS blocker + CCB or diuretic) at low doses 1
3. Step 2: If BP remains uncontrolled, increase to full doses 1
4. Step 3: If BP still uncontrolled, use triple therapy with RAS blocker + CCB + thiazide/thiazide-like diuretic, preferably as a single-pill combination 1
5. Step 4: For resistant hypertension (uncontrolled on triple therapy), add spironolactone (low dose 25-50 mg) 1
6. Step 5: If spironolactone is not tolerated or contraindicated, consider eplerenone, beta-blockers, alpha-blockers (doxazosin), or other agents 1

Management of Resistant Hypertension

• Resistant hypertension is defined as BP that remains uncontrolled despite treatment with three or more antihypertensive drugs including a diuretic 1
• Key management steps include:
  • Reinforcement of lifestyle measures, especially sodium restriction 1
  • Addition of low-dose spironolactone (25-50 mg daily) 1
  • If spironolactone is not tolerated, alternatives include eplerenone, amiloride, higher-dose thiazide diuretics, beta-blockers, or alpha-blockers 1
  • Consider referral to a specialist for patients with truly resistant hypertension 1

Non-Pharmacological Interventions

• Lifestyle modifications should be recommended for all patients with hypertension 1:
  • Weight loss for overweight/obese patients
  • Adoption of DASH dietary pattern (high in fruits, vegetables, whole grains; low in sodium)
  • Sodium restriction (<2g/day)
  • Increased physical activity (150 minutes/week of moderate-intensity exercise)
  • Limited alcohol consumption
  • Smoking cessation 1, 2

Common Pitfalls to Avoid

• Combining two RAS blockers (ACE inhibitor + ARB) is not recommended due to increased adverse effects without additional benefit 1
• Delayed intensification of therapy when BP remains uncontrolled (clinical inertia) 1
• Poor adherence assessment before adding new medications or increasing doses 1
• Inappropriate drug selection for specific comorbidities (e.g., non-dihydropyridine CCBs in heart failure) 1
• Inadequate monitoring of electrolytes and renal function, especially when using RAS blockers and/or diuretics 1

Improving Medication Adherence

• Use single-pill combinations whenever possible 1
• Prescribe once-daily dosing regimens 1
• Link medication-taking to daily habits 1
• Implement home BP monitoring to provide feedback to patients 1
• Consider multidisciplinary approaches involving pharmacists and other healthcare team members 1