Starting Dose for a 17-Year-Old Male with Hypertension
For a 17-year-old male with hypertension, initiate treatment with an ACE inhibitor (lisinopril 5 mg once daily), ARB, long-acting calcium channel blocker (amlodipine 2.5-5 mg once daily), or thiazide diuretic, starting at the low end of the dosing range. 1
First-Line Medication Options
The 2017 AAP Pediatric Hypertension Guidelines recommend four equally acceptable first-line agents 1:
- ACE inhibitors: Starting dose of lisinopril 5 mg once daily (or 0.07 mg/kg, up to 5 mg) 2
- ARBs: Alternative to ACE inhibitors with similar efficacy 1
- Long-acting calcium channel blockers: Amlodipine 2.5-5 mg once daily 3, 4
- Thiazide diuretics: Effective add-on or initial therapy 1
Specific Dosing Recommendations
For ACE Inhibitors (e.g., Lisinopril)
- Initial dose: 5 mg once daily for adolescents 2
- Titration: Increase every 2-4 weeks based on blood pressure response 1
- Maximum dose: Up to 40 mg daily 2
- Target BP: <130/80 mmHg for patients ≥13 years 1
For Calcium Channel Blockers (e.g., Amlodipine)
- Initial dose: 2.5-5 mg once daily 3, 4
- Pediatric studies: Effective doses ranged from 0.16-0.29 mg/kg/day 5
- Maximum dose: 10 mg daily 3
- Advantage: Can be compounded into liquid if needed 6, 7
Critical Clinical Considerations
Special Populations Requiring ACE Inhibitor/ARB as First Choice
If this patient has any of the following, ACE inhibitor or ARB is mandatory as initial therapy 1:
- Chronic kidney disease
- Proteinuria
- Diabetes mellitus
Contraindications and Warnings
- ACE inhibitors/ARBs are absolutely contraindicated in pregnancy - counsel all adolescent females of childbearing potential about this risk 1
- Beta-blockers are NOT recommended as initial therapy in pediatric hypertension due to expanded adverse effects and lack of improved outcomes compared to other agents 1, 8
- For African American patients, consider higher initial ACE inhibitor doses or start with thiazide/calcium channel blocker due to potentially reduced ACE inhibitor response 1
Treatment Algorithm
Step 1: Initial Monotherapy
Start with one medication at the low end of dosing range 1:
- Lisinopril 5 mg daily OR
- Amlodipine 2.5-5 mg daily OR
- Thiazide diuretic OR
- ARB
Step 2: Titration Schedule
- Increase dose every 2-4 weeks until BP controlled (<130/80 mmHg for age ≥13 years) 1
- Follow-up visits every 4-6 weeks until BP normalized 1
- Use home BP measurements to guide titration between visits 1
Step 3: If Monotherapy Fails
- Add a second agent from a different class rather than switching 1
- Titrate the second agent as with the initial medication 1
Step 4: Monitoring
- After BP control achieved, extend follow-up to every 3-4 months 1
- Consider ambulatory BP monitoring (ABPM) to confirm control 1
- Monitor for medication-specific adverse effects (e.g., electrolytes with diuretics, cough with ACE inhibitors) 1
Common Pitfalls to Avoid
- Do not start with beta-blockers unless the patient has specific indications like tachycardia 1, 8
- Do not delay pharmacologic treatment if patient has stage 2 hypertension, symptomatic hypertension, or target organ damage 1
- Do not forget pregnancy counseling when prescribing ACE inhibitors/ARBs to adolescents 1
- Do not use adult starting doses - always start at the low end of pediatric dosing ranges 1