What are the recommended first-line oral medications for hypertension management?

First-Line Oral Medications for Hypertension Management

The recommended first-line oral medications for hypertension management are thiazide or thiazide-like diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs). 1

General Approach to First-Line Therapy

Patient Characteristics to Consider

• Race/Ethnicity:

  • Black patients: Initial treatment should include a thiazide-type diuretic or CCB 1
  • Non-black patients: Any of the four major drug classes can be used (ACE inhibitors, ARBs, CCBs, thiazide diuretics) 1

• Comorbid Conditions:

  • Diabetes: All first-line classes (diuretics, ACE inhibitors, ARBs, and CCBs) are effective 1
  • Albuminuria: ACE inhibitors or ARBs are preferred 1
  • Coronary artery disease: ACE inhibitors or ARBs are recommended first-line 1

Monotherapy vs. Combination Therapy

• For most patients with hypertension: Upfront low-dose combination therapy is recommended, preferably as single-pill combinations 1
• For patients with elevated BP but not hypertension: Monotherapy is recommended initially 1

Specific First-Line Medication Classes

1. Thiazide and Thiazide-like Diuretics

• Examples: Chlorthalidone (preferred), hydrochlorothiazide, indapamide 2, 3
• Evidence: High-quality evidence shows that first-line low-dose thiazides reduced mortality, total cardiovascular events, stroke, and coronary heart disease 3
• Considerations: May cause hyperglycemia and electrolyte disturbances; monitor potassium levels 2

2. ACE Inhibitors

• Examples: Lisinopril, enalapril, ramipril 4, 5
• Evidence: Low to moderate-quality evidence shows ACE inhibitors reduced mortality, stroke, coronary heart disease, and total cardiovascular events 3
• Considerations: May cause cough, angioedema; monitor serum creatinine and potassium; contraindicated in pregnancy 1, 4

3. Angiotensin Receptor Blockers (ARBs)

• Examples: Losartan, valsartan, candesartan
• Evidence: Effective for BP reduction with potentially fewer side effects than ACE inhibitors (less cough) 1
• Considerations: Monitor serum creatinine and potassium; contraindicated in pregnancy 1

4. Calcium Channel Blockers (CCBs)

• Examples: Amlodipine, nifedipine (dihydropyridine CCBs) 6
• Evidence: Low-quality evidence shows CCBs reduced stroke and total cardiovascular events 3
• Considerations: Dihydropyridine CCBs may cause peripheral edema 6

Treatment Algorithms by Patient Population

For Non-Black Patients:

1. Start with low-dose ACE inhibitor or ARB 1
2. Increase to full dose if needed 1
3. Add thiazide/thiazide-like diuretic 1
4. Add CCB if BP remains uncontrolled 1

For Black Patients:

1. Start with low-dose ARB + dihydropyridine CCB or CCB + thiazide/thiazide-like diuretic 1
2. Increase to full dose 1
3. Add diuretic or ACE inhibitor/ARB (whichever was not initially used) 1

Common Pitfalls and Caveats

• Avoid combining ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 1
• Beta-blockers are not recommended as first-line agents unless the patient has ischemic heart disease or heart failure 1
• Pregnancy considerations: ACE inhibitors, ARBs, MRAs, direct renin inhibitors, and neprilysin inhibitors should be avoided in sexually active individuals of childbearing potential who are not using reliable contraception 1
• Monitoring: Check serum creatinine and potassium 7-14 days after initiation or dose change of ACE inhibitors, ARBs, or MRAs 1
• Adherence: Single-pill combinations may improve medication adherence 1

Target Blood Pressure Goals

• General population: <130/80 mmHg 1
• Elderly patients: Individualize based on frailty 1
• Patients with diabetes or chronic kidney disease: <130/80 mmHg 1

Remember that lifestyle modifications (weight loss, DASH diet, sodium restriction, physical activity, and alcohol moderation) should be implemented alongside pharmacologic therapy for optimal blood pressure management 1, 7.