Preferred Strategy for Dosing Antihypertensive Medications
The correct answer is B: The preferred strategy is to start one drug and then add a second drug before achieving maximum dose of the initial drug. This stepped-care approach is recommended by the American College of Cardiology and represents current best practice for most patients initiating antihypertensive therapy 1.
Rationale for the Stepped-Care Approach
The American College of Cardiology explicitly recommends a stepped-care approach defined as initiation with a single agent followed by sequential titration and addition of other agents before reaching maximum dose of the first drug 1.
This strategy has been the standard recommended by the National High Blood Pressure Education Program since 2003 1.
Adding a second medication from a different class is more effective than maximizing the dose of a single agent, as most adults with hypertension (approximately 75%) will require multiple medications to achieve blood pressure control 1.
Why Option A Is Incorrect
Titrating a single drug to maximum dose before adding a second agent is not the preferred strategy according to current American College of Cardiology and Hypertension guidelines 1.
This approach delays achievement of blood pressure control and may expose patients to higher doses of a single agent, potentially increasing dose-dependent adverse effects without proportional efficacy gains 2.
The dose-response curve for most antihypertensives flattens at higher doses, making it less effective to maximize single-drug dosing 2.
Why Option C Is Incorrect
For blood pressures in the "elevated" range (systolic 120-129 mmHg and diastolic <80 mmHg), lifestyle modifications are recommended first, not pharmacologic therapy 1.
Antihypertensive medications are initiated when blood pressure reaches stage 1 hypertension (≥130/80 mmHg in diabetes patients) or ≥140/90 mmHg in general populations 3.
Initial Treatment Strategy Based on Blood Pressure Severity
For Stage 1 Hypertension (130-159/80-99 mmHg):
- Begin with a single antihypertensive agent 3, 1.
- If blood pressure goal is not achieved at initial doses, add a second drug from a different class rather than maximizing the first drug 1.
For Stage 2 Hypertension (≥160/100 mmHg):
- Initiate treatment with two antihypertensive medications simultaneously to more effectively achieve adequate blood pressure control 3.
- Single-pill combination products may improve medication adherence 3.
Medication Selection and Combination Strategy
Initial drug selections should include agents proven to reduce cardiovascular events in clinical trials: ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers 3.
When combining agents, choose drugs with complementary mechanisms of action (e.g., renin-angiotensin system blocker + calcium channel blocker + diuretic) 1, 4.
For patients with albuminuria (≥30 mg/g), initial treatment should include an ACE inhibitor or ARB to reduce progressive kidney disease risk 3.
Monitoring and Titration Timeline
Blood pressure should be monitored and medications adjusted every 2-4 weeks until control is achieved 1.
The goal is to achieve blood pressure control within 3 months of initiating therapy 1.
For patients on ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium at least annually 3.
Common Pitfalls to Avoid
Avoid therapeutic inertia: Waiting too long to add a second agent delays achievement of blood pressure control and increases cardiovascular risk 1.
Never combine ACE inhibitors with ARBs or direct renin inhibitors, as dual RAAS blockade increases adverse events without additional benefit 3, 1.
Don't use combinations with similar mechanisms of action, as this provides no additional efficacy and may increase side effects 1.
Consider fixed-dose combination products to improve adherence when appropriate, as single-pill combinations substantially improve patient compliance compared to separate agents 4, 5.