What are the recommended dosages of anti-hypertensive medications, such as Angiotensin-Converting Enzyme (ACE) inhibitors, Calcium Channel Blockers (CCBs), and Thiazide Diuretics?

Recommended Dosages of Antihypertensive Medications

The recommended initial antihypertensive therapy should include one or more of the four major drug classes: thiazide/thiazide-like diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers, with specific dosing based on patient characteristics and severity of hypertension. 1

First-Line Medication Classes and Initial Dosing

Thiazide and Thiazide-like Diuretics

• Chlorthalidone: 12.5-25 mg once daily (maximum 100 mg daily) 2
• Hydrochlorothiazide: 25 mg once or twice daily (maximum 200 mg daily) 2
• Indapamide: 2.5 mg once daily (maximum 5 mg daily) 2
• Chlorthalidone is preferred over hydrochlorothiazide due to superior 24-hour blood pressure control 3

ACE Inhibitors

• Lisinopril: Initial dose 10 mg once daily, usual range 20-40 mg daily (maximum 80 mg daily) 4
• For patients already taking diuretics, start with lower dose (5 mg daily) to prevent hypotension 4
• For patients with renal impairment (CrCl ≤30 mL/min), reduce initial dose by half 4

Angiotensin Receptor Blockers (ARBs)

• Initial therapy with low dose ARB, then titrate to full dose 2
• Preferred over ACE inhibitors in Black patients of African or Caribbean family origin 2

Calcium Channel Blockers (Dihydropyridine)

• Start with low dose and titrate as needed 2
• Particularly effective in Black patients 2, 1

Treatment Strategy Based on Patient Characteristics

Non-Black Patients

1. Start with low dose ACE inhibitor/ARB 2
2. Increase to full dose if needed 2
3. Add thiazide/thiazide-like diuretic 2
4. Add spironolactone (12.5-25 mg daily, maximum 50 mg) or alternative fourth agent if needed 2

Black Patients

1. Start with low dose ARB plus dihydropyridine CCB or thiazide-like diuretic 2
2. Increase to full dose 2
3. Add diuretic or ACE inhibitor/ARB if not already included 2
4. Add spironolactone or alternative fourth agent if needed 2

Combination Therapy Approach

• For blood pressure 130/80-150/90 mmHg: Consider starting with a single agent 2
• For blood pressure ≥150/90 mmHg: Start with two-drug combination 2
• Preferred combinations include ACE inhibitor/ARB with either CCB or thiazide diuretic 2, 1
• Single-pill combinations improve adherence 2
• Never combine ACE inhibitors with ARBs due to increased adverse effects 1

Special Populations and Comorbidities

• Diabetes: ACE inhibitor or ARB preferred as first-line therapy 2, 1
• Chronic kidney disease with albuminuria: ACE inhibitor or ARB recommended 2, 1
• Heart failure: ACE inhibitor/ARB plus beta-blocker, with diuretics as needed 2
• Elderly (≥80 years): Consider monotherapy with lower starting doses 2
• Pregnancy: ACE inhibitors, ARBs, MRAs, direct renin inhibitors, and neprilysin inhibitors are contraindicated 2

Resistant Hypertension Management

• For patients not meeting BP targets on three classes of medications (including a diuretic), add mineralocorticoid receptor antagonist (spironolactone 12.5-25 mg daily) 2
• Monitor serum potassium and renal function when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 2

Monitoring and Follow-up

• Target: BP <130/80 mmHg for most adults; individualize for elderly based on frailty 2
• Monitor BP control and aim to achieve target within 3 months 2
• For patients on ACE inhibitors, ARBs, and MRAs, check serum creatinine and potassium 7-14 days after initiation or dose change 2
• Monitor for hypokalemia when diuretics are used 2

Common Pitfalls to Avoid

• Underdosing medications, particularly ACE inhibitors which have a flat dose-response curve but shorter duration of action at lower doses 5
• Failing to initiate combination therapy for patients with BP ≥20/10 mmHg above target 6
• Overlooking the need for different initial therapy in Black patients 2, 1
• Combining ACE inhibitors with ARBs, which increases adverse effects without additional benefit 1
• Neglecting to monitor electrolytes and renal function when using RAS blockers and diuretics 2