What medications are taken for hypertension?

Medications for Hypertension

First-line medications for hypertension include ACE inhibitors (such as lisinopril), ARBs (such as losartan), thiazide-like diuretics (such as chlorthalidone), and dihydropyridine calcium channel blockers (such as amlodipine). 1

Initial Drug Selection Based on Blood Pressure Level

For blood pressure 130-150/80-90 mmHg:

• Start with a single medication from the first-line classes 1
• Choose ACE inhibitor or ARB if coronary artery disease or albuminuria (urine albumin ≥30 mg/g) is present 1

For blood pressure ≥150/90 mmHg:

• Start with two antihypertensive medications simultaneously to achieve blood pressure goals more effectively 1
• Single-pill combination products may improve medication adherence 1

Race-Specific Considerations

For non-Black patients:

• Start with low-dose ACE inhibitor or ARB 1
• Add dihydropyridine calcium channel blocker as second agent 1
• Increase to full dose if blood pressure remains elevated 1

For Black patients:

• Start with low-dose ARB combined with either a dihydropyridine calcium channel blocker OR a thiazide-like diuretic 1
• This combination approach is preferred over monotherapy 1

Stepwise Medication Escalation

Third-line therapy:

• Add a thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide due to superior cardiovascular event reduction) 1

Fourth-line therapy for resistant hypertension:

• Add spironolactone as the preferred agent 1
• Alternatives if spironolactone is not tolerated: amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Specific Clinical Scenarios

Diabetes with hypertension:

• ACE inhibitors or ARBs are first-line for those with coronary artery disease 1
• ACE inhibitors or ARBs are mandatory for albuminuria (UACR ≥30 mg/g) to reduce progressive kidney disease 1

Heart failure:

• Lisinopril (ACE inhibitor) is indicated to reduce signs and symptoms of systolic heart failure 2

Post-myocardial infarction:

• Lisinopril is indicated for mortality reduction in hemodynamically stable patients within 24 hours of acute MI 2

Critical Monitoring Requirements

When using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists:

• Monitor serum creatinine and potassium at routine visits 1
• Recheck 7-14 days after initiation or dose changes 1

When using diuretics:

• Monitor for hypokalemia at routine visits 1

Absolute Contraindications

Avoid in pregnancy or those of childbearing potential without reliable contraception:

• ACE inhibitors 1
• ARBs 1
• Mineralocorticoid receptor antagonists 1
• Direct renin inhibitors 1
• Neprilysin inhibitors 1

Target Blood Pressure Goals

Most adults <65 years:

• Target <130/80 mmHg 1, 3

Adults ≥65 years:

• Target systolic <130 mmHg, individualized based on frailty 1

Home blood pressure monitoring target:

• <135/85 mmHg 1

Timeline for Blood Pressure Control

• Achieve target blood pressure within 3 months of treatment initiation 1
• Allow 2-4 weeks for full effect of dose adjustments before making further changes 4

Common Pitfalls to Avoid

• Do not use monotherapy in patients with blood pressure ≥150/90 mmHg 1
• Do not add additional medications without first optimizing current medication doses 4
• Do not use short-acting nifedipine for hypertensive urgencies due to risk of precipitous blood pressure drops 5
• Always verify medication adherence before escalating therapy, as non-adherence is a common cause of inadequate control 1, 4

When to Refer to Specialist

• Blood pressure remains uncontrolled despite adherence to a four-drug regimen including a diuretic 1
• Suspected secondary hypertension requiring additional evaluation 1