What is the approach and treatment for new onset hypertension in an adult, including commonly used medications in India?

Approach and Treatment of New Onset Hypertension in Adults in India

The recommended approach for new onset hypertension in adults in India begins with accurate diagnosis followed by lifestyle modifications, and if needed, pharmacological therapy with thiazide diuretics, ACE inhibitors, ARBs, or calcium channel blockers based on patient characteristics and comorbidities. 1

Diagnosis and Assessment

• Blood pressure (BP) should be measured using a validated device with appropriate cuff size, with the average of at least 2 readings taken at each of 2-3 office visits 1
• Hypertension is diagnosed when office BP readings consistently show ≥140/90 mmHg, particularly if home BP is ≥135/85 mmHg or 24-hour ambulatory BP is ≥130/80 mmHg 1
• Initial evaluation should focus on identifying target organ damage, cardiovascular risk factors, and possible secondary causes of hypertension 1
• Screen for secondary hypertension in patients with resistant hypertension, sudden onset of hypertension, age <30 years, or signs suggesting underlying conditions 1

Non-Pharmacological Management

All patients with hypertension should receive advice on lifestyle modifications:

• Dietary modifications: DASH diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced saturated and total fat 1, 2
• Sodium restriction: <1500 mg/day or at minimum a reduction of 1000 mg/day 1
• Potassium intake: Increase to 3500-5000 mg/day 1
• Weight reduction: Target ideal body weight or at least 1 kg weight loss if overweight/obese 1, 3
• Physical activity: 90-150 minutes/week of aerobic or dynamic resistance exercise, or 3 sessions/week of isometric resistance exercise 1, 3
• Alcohol moderation: ≤2 drinks per day for men, ≤1 per day for women 1

Pharmacological Management

When to Initiate Drug Therapy:

• Stage 1 Hypertension (140-159/90-99 mmHg):

  • Start immediate drug therapy in high-risk patients (with CVD, CKD, diabetes, target organ damage, or aged 50-80 years) 1
  • For low-risk patients, try lifestyle modifications for 3-6 months before starting medications 1

• Stage 2 Hypertension (≥160/100 mmHg):

  • Start drug therapy immediately along with lifestyle modifications 1

First-Line Medications Available in India:

• Thiazide or thiazide-like diuretics: Hydrochlorothiazide, chlorthalidone, indapamide 4
• ACE inhibitors: Ramipril, enalapril, lisinopril 4
• Angiotensin Receptor Blockers (ARBs): Losartan, telmisartan, olmesartan 5, 4
• Calcium Channel Blockers (CCBs): Amlodipine, cilnidipine (commonly used in India) 6, 4
• Beta-blockers: Not first-line unless specific indications exist (e.g., coronary artery disease, heart failure) 1

Treatment Strategy:

1. For Stage 1 Hypertension (140-159/90-99 mmHg):

   • Start with monotherapy (single agent) at low dose 1
   • For non-black patients: Start with ACE inhibitor or ARB 1
   • For black patients: Start with CCB or thiazide diuretic 1

2. For Stage 2 Hypertension (≥160/100 mmHg):

   • Initiate with two-drug combination (preferably as single pill combination for better adherence) 1
   • Recommended combinations: ACE inhibitor/ARB + CCB or ACE inhibitor/ARB + thiazide diuretic 1

3. If BP remains uncontrolled:

   • Increase to full dose of initial medication(s) 1
   • Add a third agent from a different class 1
   • Consider adding spironolactone for resistant hypertension 1

Special Populations

• Diabetes: ACE inhibitor or ARB preferred, especially with albuminuria 1
• Chronic Kidney Disease: ACE inhibitor or ARB preferred 1
• Coronary Artery Disease: Beta-blockers and ACE inhibitors/ARBs recommended 1
• Heart Failure: ACE inhibitors/ARBs, beta-blockers, and diuretics recommended 1
• Elderly patients: Start with lower doses and titrate gradually to avoid orthostatic hypotension 1

Monitoring and Follow-up

• For patients starting drug therapy, follow up approximately monthly for dose adjustments until BP is controlled 1
• Once BP is controlled, follow up every 3-6 months 1
• Target BP should be <140/90 mmHg for most adults 1
• For patients with diabetes or CKD, target BP should be <130/80 mmHg 1
• Monitor for medication side effects and adherence at each visit 1

Common Pitfalls to Avoid

• White coat hypertension: Confirm office readings with home or ambulatory BP monitoring 1
• Medication non-adherence: Use once-daily dosing and fixed-dose combinations when possible to improve adherence 1
• Inadequate dosing: Titrate medications to effective doses before adding new agents 1
• Ignoring lifestyle modifications: Continue to emphasize non-pharmacological approaches even after starting medications 7, 3
• Drug interactions: Be aware of potential interactions with commonly used medications 1

Referral to Specialist

Consider referral to a hypertension specialist in cases of:

• Resistant hypertension (BP uncontrolled on ≥3 medications including a diuretic) 1
• Suspected secondary hypertension 1
• Significant renal disease 1
• Complex comorbidities requiring specialized management 1