What are the preferred antihypertensive medications in young patients?

Preferred Antihypertensive Medications in Young Patients

In young patients with hypertension, ACE inhibitors or angiotensin receptor blockers (ARBs) should be the first-line pharmacologic treatment after lifestyle modifications have been implemented. 1

Initial Assessment and Management

• Blood pressure should be measured at every clinic visit, with hypertension defined as BP ≥90th percentile for age, sex, and height or, in adolescents ≥13 years, ≥120/80 mmHg on three separate measurements 1
• For elevated blood pressure (90th to <95th percentile or 120-129/<80 mmHg in adolescents ≥13 years), first-line treatment is lifestyle modification focused on healthy nutrition, physical activity, sleep, and weight management 1
• Ambulatory blood pressure monitoring should be strongly considered in youth with high blood pressure readings to confirm the diagnosis and rule out white coat hypertension 1

Pharmacologic Treatment Algorithm

First-Line Therapy

• For confirmed hypertension (BP consistently ≥95th percentile or ≥130/80 mmHg in adolescents ≥13 years), ACE inhibitors or ARBs should be initiated in addition to lifestyle modifications 1
• ACE inhibitors like lisinopril have demonstrated efficacy in pediatric patients with dose-dependent antihypertensive effects 2
• These agents are particularly beneficial because they:
  • Provide renoprotection beyond blood pressure control 3, 4
  • Reduce proteinuria in children with kidney disease 4
  • Have favorable long-term safety profiles 5

Special Considerations

• In youth with diabetes and hypertension, ACE inhibitors or ARBs are strongly recommended, especially if there is evidence of albuminuria 1
• Due to potential teratogenic effects, reproductive counseling should be provided, and these medications should be avoided in adolescents of childbearing age who are not using reliable contraception 1
• Lisinopril has been shown to be effective in pediatric patients 6 to 16 years of age with dose-dependent antihypertensive efficacy 2

Monitoring and Follow-up

• Monitor serum creatinine/eGFR and potassium levels at baseline, 7-14 days after initiation or dose change, and at least annually thereafter 3
• The goal of treatment is blood pressure <90th percentile for age, sex, and height or <130/80 mmHg in adolescents ≥13 years 1
• Urine albumin-to-creatinine ratio should be monitored annually in patients with diabetes or kidney disease 1, 3

Important Cautions and Pitfalls

• Beta blockers are not recommended as initial treatment for hypertension in children due to their expanded adverse effect profile compared to other agents 6
• Beta blockers can cause significant side effects including growth impairment, school performance issues, depression, fatigue, bradycardia, hypotension, and sleep disturbances 6
• Short-acting calcium channel blockers (particularly dihydropyridines) may worsen intraglomerular hypertension and are not recommended as first-line agents 7
• Avoid combination therapy of ACE inhibitors and ARBs due to increased risk of adverse events without additional benefit 3
• In patients with significant renal dysfunction, fosinopril may be preferred among ACE inhibitors due to reduced requirement for dosage adjustment 8

Ethnic Considerations

• ACE inhibitors have less effect on blood pressure in Black patients compared to non-Black patients 2
• For Black young patients, calcium channel blockers or thiazide diuretics may need to be considered if response to ACE inhibitors or ARBs is inadequate 1, 2

By following this evidence-based approach to antihypertensive therapy in young patients, clinicians can effectively manage hypertension while minimizing adverse effects and providing organ protection.