What is the initial treatment of hypertension (HTN)?

From the Guidelines

The initial treatment of hypertension (HTN) should begin with lifestyle modifications and pharmacological therapy using ACE inhibitors or ARBs as first-line medications, especially for patients with diabetes or chronic kidney disease, as recommended by the most recent guidelines 1. The choice of initial pharmacological therapy depends on patient characteristics, with ACE inhibitors or ARBs being preferred for patients with diabetes or chronic kidney disease.

• For patients with diabetes and established coronary artery disease, ACE inhibitors or ARBs are recommended as first-line therapy for hypertension 1.
• For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g), initial treatment should include an ACE inhibitor or ARB to reduce the risk of progressive kidney disease 1.
• Multiple-drug therapy is generally required to achieve blood pressure targets, but combinations of ACE inhibitors and angiotensin receptor blockers, and combinations of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors, should not be used 1.
• The target blood pressure should be below 130/80 mmHg for most adults, and medication should be started at a low dose and titrated upward every 2-4 weeks until blood pressure control is achieved.
• Regular monitoring of serum creatinine/estimated glomerular filtration rate and serum potassium levels is essential for patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic 1. Key lifestyle modifications include weight loss if overweight, adopting the DASH diet, reducing sodium intake to less than 2.3g daily, regular physical activity, and limiting alcohol consumption.
• These lifestyle interventions are reasonable for individuals with diabetes and mildly elevated blood pressure and should be initiated along with pharmacologic therapy when hypertension is diagnosed 1.

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2. 1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. For Control of Hypertension: The adult initial dose of hydrochlorothiazide capsules is one capsule given once daily whether given alone or in combination with other antihypertensives.

The initial treatment of hypertension can be started with lisinopril (PO) at a dose of 10 mg once a day or hydrochlorothiazide (PO) at a dose of one capsule given once daily.

• The dosage of lisinopril should be adjusted according to blood pressure response, with a usual dosage range of 20 mg to 40 mg per day.
• The total daily dose of hydrochlorothiazide should not exceed 50 mg. 2 3

From the Research

Initial Treatment of Hypertension

The initial treatment of hypertension typically involves lifestyle modifications and, if necessary, medication.

• Lifestyle modifications include:
  • Weight loss
  • Healthy dietary pattern with low sodium and high potassium intake
  • Physical activity
  • Moderation or elimination of alcohol consumption 4, 5
• First-line medication options include:
  • Thiazide or thiazide-like diuretics (e.g., hydrochlorothiazide or chlorthalidone)
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (e.g., enalapril or candesartan)
  • Calcium channel blockers (e.g., amlodipine) 4, 6, 7

Blood Pressure Targets

The target blood pressure levels vary depending on age and other factors.

• For adults under 65 years, the target is typically less than 130/80 mm Hg 4
• For adults 65 years and older, the target is typically less than 130 mm Hg for systolic blood pressure 4
• For patients with chronic kidney disease or diabetes, the target is typically less than 140/90 mm Hg 7

Combination Therapy

Combination therapy may be necessary for patients who do not respond to monotherapy or lifestyle modifications.

• More than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents 6
• The choice of combination therapy depends on various factors, including the patient's underlying health conditions and the presence of certain comorbidities 6, 8