What is the recommended approach for starting someone on blood pressure medication?

Recommended Approach for Starting Blood Pressure Medications

For patients with hypertension, the recommended approach is to start with a low-dose ACE inhibitor or ARB for non-black patients, and a low-dose ARB plus dihydropyridine calcium channel blocker (DHP-CCB) or DHP-CCB plus thiazide/thiazide-like diuretic for black patients, with subsequent dose adjustments based on blood pressure response. 1

Initial Assessment and Treatment Decision

• Confirm hypertension diagnosis with office BP ≥140/90 mmHg, particularly if home BP ≥135/85 mmHg or 24h ambulatory BP ≥130/80 mmHg 1
• Determine hypertension severity:
  • Grade 1 (140-159/90-99 mmHg): Start lifestyle interventions for all patients 1
  • Grade 2 (≥160/100 mmHg): Start drug treatment immediately along with lifestyle interventions 1

Treatment Algorithm Based on Patient Characteristics

For Non-Black Patients:

1. Start with low-dose ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily) 1, 2, 3
2. Increase to full dose if blood pressure remains uncontrolled (e.g., lisinopril 20-40 mg, losartan 100 mg) 2, 3
3. Add thiazide/thiazide-like diuretic if target BP not achieved 1
4. Add spironolactone or alternatives (amiloride, doxazosin, eplerenone, clonidine, beta-blocker) if needed 1

For Black Patients:

1. Start with low-dose ARB (e.g., losartan 50 mg daily) plus DHP-CCB or DHP-CCB plus thiazide/thiazide-like diuretic 1, 3
2. Increase to full dose if blood pressure remains uncontrolled 1
3. Add diuretic or ACE/ARB if not already included 1
4. Add spironolactone or alternatives (amiloride, doxazosin, eplerenone, clonidine, beta-blocker) if needed 1

Special Considerations

• For elderly patients (>80 years) or frail individuals: Consider monotherapy at lower starting doses 1

  • For lisinopril, start with 5 mg daily in patients taking diuretics 2
  • For losartan, consider 25 mg daily in patients with possible intravascular depletion (e.g., on diuretic therapy) 3

• For patients with renal impairment:

  • With creatinine clearance ≥10 mL/min and ≤30 mL/min, reduce initial dose of lisinopril to half (5 mg) 2
  • For patients on hemodialysis or creatinine clearance <10 mL/min, start lisinopril at 2.5 mg daily 2

Dosing Strategies and Monitoring

• Use once-daily dosing and single-pill combinations when possible to improve adherence 1, 4
• Target BP should be <130/80 mmHg for most patients, with a minimum reduction of 20/10 mmHg 1, 4
• Monitor BP control and aim to achieve target within 3 months 1
• Low doses are often effective and well-tolerated; adding a second agent at low dose is preferable to maximizing the dose of a single agent to avoid adverse effects 5

Common Pitfalls to Avoid

• Underdosing medications: Many physicians prescribe lower doses than those proven effective in clinical trials 6
• Failing to initiate combination therapy in high-risk patients: Evidence suggests patients with high cardiovascular risk benefit from starting immediately on combination therapy 7
• Inadequate follow-up: Regular monitoring is essential to assess efficacy and adjust therapy accordingly 1
• Not accounting for racial differences in treatment response: Black patients typically respond better to calcium channel blockers and diuretics than to ACE inhibitors or ARBs as monotherapy 1

When to Refer

• If BP remains uncontrolled despite optimal medical therapy, refer to a provider with expertise in hypertension management 1, 4