What are the recommended medications and doses for managing hypertension?

Recommended Medications and Doses for Managing Hypertension

For most patients with confirmed hypertension (BP ≥140/90 mmHg), combination therapy is recommended as initial treatment, preferably using a single-pill combination of a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker (CCB) or a thiazide/thiazide-like diuretic. 1

First-Line Medications and Dosing

Preferred Initial Combination Therapy

• RAS Blockers + CCB or Diuretic (single-pill combination preferred) 1
  • ACE inhibitors (e.g., Lisinopril 10 mg daily, titrate to 20-40 mg daily) 2
  • ARBs (e.g., Losartan 50 mg daily, titrate up to 100 mg daily) 1, 3
  • Dihydropyridine CCBs (e.g., Amlodipine 5 mg daily, titrate up to 10 mg daily) 1
  • Thiazide/thiazide-like diuretics (e.g., Indapamide 1.5 mg modified-release daily or 2.5 mg daily, Chlorthalidone 12.5-25 mg daily) 1

Special Population Considerations

• Black patients of African or Caribbean origin: Consider ARB + CCB or CCB + thiazide-like diuretic as initial therapy 1
• Elderly patients (≥80 years): Consider monotherapy initially with gradual dose titration 1
• Patients with orthostatic hypotension or frailty: Consider monotherapy initially 1

Step-wise Treatment Algorithm

Step 1: Initial Therapy

• For most patients: Start with low-dose combination of RAS blocker + CCB or RAS blocker + diuretic 1
• For specific populations (elderly ≥85 years, frail, orthostatic hypotension): Consider monotherapy 1
• Target: Reduce BP to 120-129/70-79 mmHg in most adults if tolerated 1

Step 2: If BP Not Controlled

• Increase to full doses of initial combination 1
• Ensure medication adherence before escalating therapy 1

Step 3: Triple Therapy

• Add the third agent (RAS blocker + CCB + thiazide/thiazide-like diuretic) 1
• Preferably as a single-pill combination to improve adherence 1

Step 4: Resistant Hypertension Management

• Add spironolactone 25 mg daily (if serum potassium ≤4.5 mmol/L) 1, 4
• If spironolactone not tolerated or contraindicated, consider:
  • Eplerenone 50-200 mg daily 1
  • Beta-blocker (preferably vasodilating type like carvedilol, labetalol, or nebivolol) 1
  • Alpha-blocker (e.g., doxazosin) 1
  • Amiloride 1

Important Clinical Considerations

Drug Selection Based on Comorbidities

• Heart failure: ACE inhibitor/ARB + beta-blocker + diuretic 1
• Chronic kidney disease: ACE inhibitor/ARB (monitor renal function and potassium) 1
• Diabetes: ACE inhibitor/ARB as part of combination therapy 1

Monitoring and Follow-up

• Reassess BP control within 3 months of starting therapy 1
• Monitor serum electrolytes and renal function 1 month after initiating diuretics or RAS blockers 1
• Adjust treatment to achieve target BP of 120-129 mmHg systolic for most adults 1

Common Pitfalls to Avoid

• Avoid combining two RAS blockers (ACE inhibitor + ARB) due to increased risk of adverse effects without additional benefit 1
• Avoid rapid dose escalation in elderly patients, which may lead to orthostatic hypotension 1
• Don't discontinue medications if first BP measurement is at goal; treatment should be lifelong 1
• Don't overlook lifestyle modifications which enhance pharmacological therapy effectiveness 5

Special Situations

Hypertensive Crisis

• For hypertensive emergency with target organ damage: IV labetalol, oral methyldopa, or nifedipine 1
• For severe hypertension without organ damage: Oral agents with close follow-up 1

Resistant Hypertension

• Ensure proper BP measurement technique and medication adherence 6
• Rule out secondary causes of hypertension 6
• Emphasize sodium restriction 1
• Add spironolactone 25 mg daily as fourth-line agent 1, 6

By following this evidence-based approach to hypertension management, clinicians can effectively reduce cardiovascular risk and improve patient outcomes through appropriate medication selection and dosing.