What is the best initial antihypertensive (high blood pressure) medication class to start a patient on?

Best Initial Antihypertensive Medication Class

For most patients with hypertension, initial treatment should include any of the following first-line drug classes: thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), or long-acting dihydropyridine calcium channel blockers (CCBs). 1, 2

First-line Options Based on Current Guidelines

• The World Health Organization (WHO) strongly recommends using any of these four drug classes as initial treatment: thiazide/thiazide-like diuretics, ACEIs, ARBs, or long-acting dihydropyridine CCBs 1
• These drug classes have been consistently demonstrated to reduce cardiovascular events in people with hypertension 1
• For most uncomplicated hypertension cases, no single drug class has shown clear superiority over others in terms of mortality and morbidity outcomes 1, 2

Patient-Specific Considerations

Race/Ethnicity

• For Black patients, CCBs or thiazide diuretics are more effective as initial therapy compared to ACEIs or ARBs 2, 3
• Losartan (an ARB) has been shown to be effective in reducing blood pressure regardless of race, although the effect may be somewhat less in Black patients 3

Comorbid Conditions

• For patients with diabetes and established coronary artery disease, ACEIs or ARBs are recommended as first-line therapy 1, 2
• For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), initial treatment should include an ACEI or ARB to reduce the risk of progressive kidney disease 1, 2
• For patients with heart failure with reduced ejection fraction, beta-blockers are indicated, though they haven't shown mortality reduction as blood pressure-lowering agents in the absence of these conditions 1

Initiation Strategy Based on Blood Pressure Level

• For patients with blood pressure between 130/80 mmHg and 160/100 mmHg, treatment may begin with a single drug 1
• For patients with blood pressure ≥160/100 mmHg, initial treatment with two antihypertensive medications is recommended for more effective blood pressure control 1, 2
• Single-pill combinations may improve medication adherence 1, 2

Combination Therapy Approach

• Multiple-drug therapy is generally required to achieve blood pressure goals of <130/80 mmHg 1
• When combination therapy is needed, the recommended combinations include:
  • CCB + thiazide diuretic + ACEI or ARB 1, 2
  • ACEI or ARB + CCB 1, 2
  • ACEI or ARB + thiazide diuretic 1, 2

Dosing Considerations

• For amlodipine (a CCB), the usual initial antihypertensive dose is 5 mg once daily, with a maximum dose of 10 mg once daily 4
• For losartan (an ARB), the usual starting dose is 50 mg once daily, with a maximum dose of 100 mg once daily 3
• Elderly, fragile patients or those with hepatic insufficiency may require lower initial doses 3, 4

Common Pitfalls and Caveats

• Bedtime dosing of antihypertensive medications is not specifically recommended over morning dosing, as recent trials have not reproduced earlier benefits 1
• Beta-blockers are not recommended as first-line therapy for uncomplicated hypertension as they have been shown to be less effective than CCBs and thiazide diuretics in preventing cardiovascular events 1
• Laboratory testing before starting therapy is suggested but should not delay treatment initiation 1
• For resistant hypertension (BP ≥140/90 mmHg despite three antihypertensive drugs including a diuretic), mineralocorticoid receptor antagonist therapy should be considered 1

Follow-up Recommendations

• Monthly follow-up is suggested after initiation or change in antihypertensive medications until target blood pressure is reached 1
• For patients with controlled blood pressure, follow-up every 3-5 months is recommended 1