For a patient with hypertension, should amlodipine 5mg daily or Losartan-Potassium (Losartan and Hydrochlorothiazide) 50-12.5mg be used as initial antihypertensive therapy?

Initial Antihypertensive Therapy Recommendation

For this 50-year-old female with newly diagnosed stage 2 hypertension (BP 180/100), you should start with amlodipine 5mg daily rather than the combination of losartan-HCTZ 50-12.5mg. 1

Rationale for Monotherapy Over Combination Therapy

Start with monotherapy in this case because the patient has no documented high-risk features (no mention of CVD, CKD, diabetes, or organ damage), and the 2020 International Society of Hypertension guidelines recommend considering monotherapy in low-risk patients with grade 2 hypertension. 1

• While JNC 7 guidelines suggest considering 2-drug combination therapy when BP is >20/10 mmHg above goal, this recommendation is not absolute and should be balanced against starting with a single agent to assess tolerability and response. 1

Why Amlodipine is Preferred as Initial Monotherapy

Amlodipine demonstrates superior blood pressure reduction compared to losartan monotherapy:

• Amlodipine produces greater mean BP reductions than losartan (16.1/12.6 mmHg vs 13.7/10.3 mmHg systolic/diastolic, p=0.018 and p=0.002 respectively). 2
• Expected BP reduction with amlodipine 5-10mg is 8-10 mmHg systolic and 4-5 mmHg diastolic, compared to ARBs at 8-10/4-6 mmHg. 3
• Amlodipine shows better blood pressure variability control, with lower visit-to-visit and day-to-day BP variability compared to losartan. 4

The response rate is significantly higher with amlodipine (63.8% achieving DBP <90 mmHg vs 55.1% with losartan, though not statistically significant at p=0.07). 2

Stepwise Treatment Algorithm

Step 1: Initial Therapy

• Start amlodipine 5mg once daily. 5
• Reassess BP in 2-4 weeks. 1

Step 2: Dose Titration (if BP remains ≥140/90 mmHg)

• Increase amlodipine to 10mg daily after 7-14 days if BP goal not achieved. 5
• The FDA label indicates maximum dose is 10mg daily for hypertension. 5

Step 3: Add Second Agent (if BP remains uncontrolled on amlodipine 10mg)

• Add losartan 50mg daily (or another ACE inhibitor/ARB). 1
• This follows the ISH 2020 guideline algorithm for non-Black patients: start with CCB, then add ARB/ACEI. 1

Step 4: Add Thiazide Diuretic (if still uncontrolled)

• Add hydrochlorothiazide 12.5-25mg daily. 1

Important Clinical Considerations

Confirm the diagnosis before initiating therapy:

• This single office reading of 180/100 should be confirmed with home BP monitoring or ambulatory BP monitoring, as the ISH 2020 guidelines recommend confirming elevated office readings. 1
• If confirmed hypertensive, immediate treatment is warranted given the stage 2 elevation. 1

Target BP goals:

• General target: <140/90 mmHg. 1, 3
• If high-risk features emerge (diabetes, CKD, CVD), target <130/80 mmHg. 1, 3

Monitoring schedule:

• Reassess BP within 2-4 weeks after starting therapy. 1
• Achieve target BP within 3 months. 1
• Titrate more rapidly if clinically warranted with frequent assessment. 5

Common Pitfalls to Avoid

Do not start with the losartan-HCTZ combination because:

• Starting with a fixed-dose combination limits your ability to titrate individual components and identify which agent is causing side effects. 1
• The patient has no documented compelling indications that would favor an ARB as first-line therapy (no diabetes, CKD, heart failure, or proteinuria mentioned). 1
• Combination therapy with a diuretic increases risk of orthostatic hypotension, particularly in a treatment-naive patient. 1

Monitor for amlodipine-specific adverse effects:

• Peripheral edema is the most common side effect (more frequent than with ARBs). 2, 6
• Edema can be managed by adding an ARB if it occurs, as ARBs may reduce CCB-induced edema. 1

Ensure medication adherence:

• Once-daily dosing with amlodipine promotes better adherence. 1
• Emphasize lifestyle modifications concurrently (dietary sodium restriction, weight loss, exercise). 1