ACE Inhibitor or ARB Selection for a 17-Year-Old with Hypertension
Start with lisinopril 2.5-10 mg once daily as the first-line ACE inhibitor for this adolescent patient, as it is the only ACE inhibitor with FDA-approved pediatric dosing and demonstrated safety and efficacy in children aged 6-16 years. 1
Rationale for ACE Inhibitor as First-Line
ACE inhibitors are recommended as first-line therapy for hypertension in non-Black patients according to the International Society of Hypertension 2020 guidelines, which specifically recommend starting with low-dose ACE inhibitor or ARB therapy 2
The 2017 ACC/AHA guidelines similarly endorse ACE inhibitors as one of the four preferred initial drug classes (along with ARBs, thiazide-like diuretics, and dihydropyridine calcium channel blockers) for uncomplicated hypertension 2
Specific Drug Selection: Lisinopril
Lisinopril is the preferred ACE inhibitor for pediatric patients because:
FDA-approved pediatric dosing exists for ages 6 years and older, with demonstrated dose-dependent blood pressure reduction in clinical trials of 115 hypertensive children 1
Dosing for pediatric patients:
- Patients <50 kg: Start 0.625-2.5 mg once daily (maximum 20 mg/day)
- Patients ≥50 kg: Start 1.25-5 mg once daily (maximum 40 mg/day) 1
At the end of 2 weeks, lisinopril demonstrated antihypertensive efficacy at doses >1.25 mg (0.02 mg/kg), with dose-dependent blood pressure lowering confirmed across all demographic subgroups including age, gender, and race 1
Lisinopril can be administered as tablets or prepared as a suspension for patients unable to swallow tablets or requiring doses unavailable in tablet form 1
Alternative: ARB if ACE Inhibitor Not Tolerated
If lisinopril causes intolerable cough (the most common ACE inhibitor side effect), switch to losartan:
Losartan is FDA-approved for hypertension in pediatric patients aged 6 years and older 3
ARBs are equally effective as ACE inhibitors for blood pressure reduction and cardiovascular protection, with a lower incidence of cough 4
The International Society of Hypertension guidelines list ARBs as an equivalent alternative to ACE inhibitors for initial therapy in non-Black patients 2
Treatment Targets and Monitoring
Blood pressure goal: <130/80 mmHg (or at minimum <140/90 mmHg if lower targets cannot be safely achieved) 2
Timeline for achieving control:
- Reassess blood pressure 2-4 weeks after initiation 5
- Titrate medication dose upward if target not achieved 2
- Aim to reach blood pressure goal within 3 months of starting therapy 2, 5
Essential monitoring parameters:
- Serum creatinine and estimated glomerular filtration rate at baseline and at least annually 2
- Serum potassium at baseline and at least annually to detect hyperkalemia 2
- Home blood pressure monitoring to confirm office readings 5
Concurrent Lifestyle Modifications
Implement these non-pharmacological interventions simultaneously (Class A recommendation):
Dietary Approaches to Stop Hypertension (DASH) eating pattern: 8-10 servings of fruits/vegetables daily, 2-3 servings of low-fat dairy, sodium restriction to <2,300 mg/day 2
Weight reduction if overweight: Target BMI 20-25 kg/m² through caloric restriction 2, 5
Increased physical activity: 90-150 minutes per week of aerobic exercise 5
Alcohol moderation: No more than 1 serving per day (though less relevant for a 17-year-old) 2
Critical Caveats
Never combine ACE inhibitor with ARB - this dual renin-angiotensin system blockade increases risk of hyperkalemia, syncope, and acute kidney injury without providing additional cardiovascular benefit 2, 4
Race considerations: ACE inhibitors may be less effective in Black patients, who should preferentially start with ARB plus calcium channel blocker or thiazide-like diuretic 2
Escalation strategy if monotherapy fails: