What is the recommended approach to initiating and adjusting medication for patients with hypertension?

Recommended Approach to Initiating and Adjusting Medication for Hypertension

The recommended approach for hypertension management is to start with a combination of two first-line agents for most patients with stage 2 hypertension (≥160/100 mmHg), while a single agent is appropriate for stage 1 hypertension (140-159/90-99 mmHg), with subsequent medication adjustments to achieve target blood pressure within 3 months. 1

Initial Medication Selection

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

• Start with a single antihypertensive drug, preferably from one of the four major classes: ACE inhibitors, ARBs, thiazide/thiazide-like diuretics, or dihydropyridine calcium channel blockers 1
• For high-risk patients (with CVD, CKD, diabetes, organ damage, or aged 50-80 years), initiate drug treatment immediately along with lifestyle modifications 1
• For lower-risk patients, a 3-6 month trial of lifestyle modifications before starting medication is appropriate 1

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

• Initiate treatment with two first-line agents of different classes, either as separate agents or in a fixed-dose combination 1
• Fixed-dose single-pill combinations are preferred to improve adherence 1
• Start drug treatment immediately along with lifestyle modifications 1

Population-Specific Initial Drug Selection

Non-Black Patients:

• Start with low-dose ACE inhibitor or ARB, typically combined with either a dihydropyridine CCB or thiazide/thiazide-like diuretic 1, 2
• Example: Lisinopril starting at 10 mg once daily, adjusting to 20-40 mg daily based on blood pressure response 3

Black Patients:

• Start with a dihydropyridine calcium channel blocker or thiazide/thiazide-like diuretic 1, 2
• For patients with albuminuria, an ARB is preferred 1

Patients with Diabetes:

• For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), an ACE inhibitor or ARB is recommended as first-line therapy 1
• For patients with established coronary artery disease, ACE inhibitors or ARBs are recommended first-line 1

Medication Adjustment Strategy

Titration Approach:

• Follow a stepped-care approach with sequential titration of dose and addition of other agents 2
• Add a second medication from a different class before reaching maximum dose of the first drug 2
• Aim to achieve blood pressure control within 3 months to maintain patient confidence and ensure long-term adherence 1

When Blood Pressure Is Not at Goal:

1. Two-Drug Combination Not Effective:

   • Add a third drug, typically a combination of RAS blocker (ACE inhibitor or ARB) with a dihydropyridine CCB and a thiazide/thiazide-like diuretic 1
   • Preferably use a single-pill combination to improve adherence 1

2. Three-Drug Combination Not Effective:

   • Add spironolactone as a fourth agent 1
   • If spironolactone is not tolerated or contraindicated, consider eplerenone, beta-blocker, alpha-blocker, or centrally acting agent 1

Monitoring and Follow-up

• Monitor serum creatinine/estimated glomerular filtration rate and serum potassium levels at least annually for patients treated with ACE inhibitors, ARBs, or diuretics 1
• Assess blood pressure control every 2-4 weeks during the titration phase until target is reached 2
• Once target is achieved, follow-up can be less frequent (e.g., every 3-6 months) 1

Important Cautions and Contraindications

• Avoid combining two RAS blockers (ACE inhibitor and ARB) due to increased risk of adverse events without additional benefit 1, 2
• Use caution when initiating therapy with two drugs in older patients due to risk of hypotension or orthostatic hypotension 1
• For patients aged ≥85 years, those with symptomatic orthostatic hypotension, or moderate-to-severe frailty, consider starting with monotherapy and slower titration 1
• For patients on hemodialysis or with creatinine clearance <10 mL/min, reduce initial doses (e.g., lisinopril 2.5 mg once daily) 3

Medication Timing

• Administer medications at the most convenient time of day for the patient to improve adherence 1
• Encourage patients to take medications at the same time each day and in a consistent setting 1