What is the first-line dose for hypertension medication?

First-Line Dosing for Blood Pressure Medication

Start with a low dose of a single first-line agent: for non-Black patients, initiate an ACE inhibitor or ARB at low dose; for Black patients, start with a low-dose ARB combined with a dihydropyridine calcium channel blocker (DHP-CCB) or a thiazide-like diuretic. 1

Initial Drug Selection by Patient Population

Non-Black Patients

• Begin with low-dose ACE inhibitor or ARB as monotherapy 1
• Specific example: Lisinopril 10 mg once daily (can start at 5 mg if patient is on diuretics or has low systolic BP) 2
• If monotherapy is insufficient after titration to full dose, add a DHP-CCB, then add a thiazide-like diuretic 1

Black Patients

• Start with low-dose ARB plus DHP-CCB, or DHP-CCB plus thiazide-like diuretic 1
• This population requires combination therapy from the outset due to lower renin levels and better response to calcium channel blockers and diuretics 1

Dosing Strategy Based on Hypertension Severity

Grade 1 Hypertension (140-159/90-99 mmHg)

• Low-risk patients: Start lifestyle interventions; if BP remains elevated after 3-6 months, initiate low-dose monotherapy 1
• High-risk patients (CVD, CKD, diabetes, organ damage, or age 50-80 years): Start drug treatment immediately with low-dose monotherapy 1

Grade 2 Hypertension (≥160/100 mmHg)

• Start drug treatment immediately regardless of risk profile 1
• Consider initiating with two drugs from different classes if BP is ≥160/100 mmHg 1, 3

Specific First-Line Drug Classes and Doses

ACE Inhibitors

• Lisinopril: Start 10 mg once daily (5 mg if on diuretics); usual range 20-40 mg daily; maximum 80 mg daily 2
• Enalapril: Alternative ACE inhibitor option 3, 4
• Reduce initial dose by 50% in patients with creatinine clearance 10-30 mL/min 2

Thiazide-Like Diuretics

• Chlorthalidone or hydrochlorothiazide are preferred thiazide-like agents with proven cardiovascular benefit 3, 4
• When adding to existing therapy, start with hydrochlorothiazide 12.5 mg 2
• Thiazide diuretics have the strongest evidence for reducing all-cause mortality and stroke 4

Calcium Channel Blockers

• Amlodipine is a commonly used DHP-CCB 3
• Start at low dose and titrate to full dose before adding additional agents 1

Special Populations

Elderly and Frail Patients (>80 years)

• Consider monotherapy with more gradual dose titration 1
• Initial doses should be lower with slower titration due to increased risk of adverse effects 1
• Target BP should be individualized based on frailty, though <140/90 mmHg remains the goal if tolerated 1

Patients with Diabetes

• ACE inhibitor or ARB is first-line, particularly if albuminuria is present (UACR ≥30 mg/g) 1
• For BP 140-159/90-99 mmHg: start single agent 1
• For BP ≥160/100 mmHg: initiate with two drugs simultaneously 1

Patients with Chronic Kidney Disease

• ACE inhibitor or ARB at maximum tolerated dose is recommended first-line if UACR ≥300 mg/g 1
• Dose adjustment required when creatinine clearance <30 mL/min 2

Titration Approach

• Start at the lowest recommended dose to minimize adverse effects 1, 3
• If first drug is ineffective but well tolerated, increase to full dose before adding second agent 1
• Simplify regimen with once-daily dosing and single-pill combinations when possible 1
• Achieve target BP within 3 months of initiating therapy 1

Blood Pressure Targets

• General target: <130/80 mmHg for most patients 1, 3
• Minimum reduction: Aim for at least 20/10 mmHg decrease from baseline 1
• Alternative target: <140/90 mmHg is acceptable, particularly in elderly or frail patients 1

Common Pitfalls to Avoid

• Do not combine ACE inhibitors with ARBs - this combination is not recommended and increases risk without additional benefit 1
• Monitor serum creatinine and potassium at least annually in patients on ACE inhibitors, ARBs, or diuretics 1
• Confirm diagnosis with home BP monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg) before initiating treatment 1
• Check for medication adherence before escalating therapy or diagnosing resistant hypertension 1