What is the preferred strategy for dosing antihypertensive (blood pressure) medications in a patient who needs to start treatment?

Preferred Strategy for Dosing Antihypertensive Medications

The preferred strategy to dose antihypertensive drugs is to start one drug, then add a second drug before achieving maximum dose of the initial drug (option B). 1

Initial Approach to Antihypertensive Therapy

• The 2017 ACC/AHA guidelines recommend a stepped-care approach defined as initiation of antihypertensive drug therapy with a single agent followed by sequential titration of the dose and addition of other agents before reaching maximum dose of the first drug 1
• This approach has been the recommended treatment strategy since the first report of the National High Blood Pressure Education Program 1
• For patients with stage 1 hypertension (systolic BP 140-159 mmHg or diastolic BP 90-99 mmHg), initiation with a single antihypertensive drug is reasonable 1

When to Add a Second Drug

• JNC 8 guidelines specifically suggest starting one drug, then adding a second drug before achieving maximal dose of the first drug as one of their recommended dosing strategies 1
• Most adults with hypertension (approximately 75%) will require more than one drug to achieve BP control 1
• Adding a second medication from a different class is recommended when a single agent at initial doses fails to achieve the BP goal 1

Evidence Against Other Options

• Option A (starting one drug, titrating to maximum dose, and then adding a second drug) is not the preferred strategy according to current guidelines 1
• Option C (starting antihypertensive drugs when blood pressures are in the "elevated" range) is not supported by guidelines, which recommend lifestyle modifications first for elevated BP 1
• Option D is incorrect as there are clear preferred strategies in guidelines 1

Special Considerations

• For patients with stage 2 hypertension (systolic BP ≥160 mmHg or diastolic BP ≥100 mmHg) or BP more than 20/10 mmHg above target, initiation with two first-line agents of different classes is recommended 1
• The combination of agents with complementary mechanisms of action (RAAS blocker, calcium channel blocker, and diuretic) is recognized as rational and effective 2
• Single-pill combinations can improve adherence and are increasingly being used 2, 3

Medication Selection

• Initial drug selections should be based on trial evidence of treatment efficacy, compelling indications, and patient characteristics 1
• For most non-black patients, initial therapy often includes an ACE inhibitor or ARB 1
• For black patients, initial therapy often includes a calcium channel blocker or thiazide diuretic 1

Monitoring and Follow-up

• Blood pressure should be monitored and medications adjusted every 2-4 weeks until BP is controlled 1
• The goal is to achieve BP control within 3 months 1
• Regular monitoring of renal function and electrolytes is recommended when using ACE inhibitors, ARBs, or diuretics 1

Common Pitfalls to Avoid

• Dual RAAS blockade (combining ACE inhibitors and ARBs) should be avoided due to increased risk of adverse events 1
• Waiting too long to add a second agent can delay achievement of BP control 1
• Starting with maximum doses increases the risk of side effects, which may reduce adherence 3