What is the initial dose of medication for common conditions like hypertension or hyperlipidemia?

Initial Medication Dosing for Hypertension and Hyperlipidemia

Hypertension Initial Dosing

For newly diagnosed hypertension, start with lisinopril 10 mg once daily or an equivalent ACE inhibitor/ARB at low dose, titrating to 20-40 mg daily based on blood pressure response. 1

Blood Pressure-Based Treatment Algorithm

• BP 130-139/80-89 mmHg: Initiate lifestyle modifications for up to 3 months, then add pharmacologic therapy with ACE inhibitor or ARB if target not achieved 2

• BP 140-159/90-99 mmHg: Start single antihypertensive agent immediately alongside lifestyle modifications 2

  • First-line options with starting doses:
    • Lisinopril: 10 mg once daily (goal 20-40 mg daily) 2, 1
    • Enalapril: 5 mg once daily (goal 10-40 mg daily) 2
    • Losartan: 25-50 mg once daily (goal 25-100 mg daily) 2
    • Valsartan: 80-160 mg once daily (goal 80-320 mg daily) 2

• BP ≥160/100 mmHg: Initiate two antihypertensive medications simultaneously for more effective control 2

  • Combine ACE inhibitor/ARB with thiazide-like diuretic (chlorthalidone or indapamide preferred) or dihydropyridine calcium channel blocker 2, 3

Special Populations

• Diabetes or pre-diabetes: ACE inhibitor or ARB is preferred first-line due to favorable metabolic profile and renoprotective effects 3

  • Avoid beta-blockers if dyskinesia present as they may worsen movement disorders 3
  • Thiazide diuretics may worsen glucose tolerance 3

• Albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB is mandatory first-line therapy 2

  • Use maximum tolerated dose for UACR ≥300 mg/g 2

• Coronary artery disease: ACE inhibitor or ARB recommended as first-line 2

Renal Dosing Adjustments

• CrCl >30 mL/min: No adjustment needed 1
• CrCl 10-30 mL/min: Start lisinopril at 5 mg daily (half usual dose) 1
• CrCl <10 mL/min or hemodialysis: Start lisinopril at 2.5 mg daily 1

Hyperlipidemia Initial Dosing

For elevated LDL cholesterol, initiate pravastatin 20-40 mg once daily or atorvastatin 10 mg once daily as first-line therapy. 2

LDL-Focused Treatment

• Elevated LDL-C or non-HDL-C (triglycerides 200-500 mg/dL):
  • Pravastatin: 20-40 mg once daily (starting dose) 2
  • Atorvastatin: 10 mg once daily (starting dose) 2
  • Fluvastatin: 20-40 mg once daily (reasonable alternative) 2

Triglyceride-Focused Treatment

• Triglycerides ≥500 mg/dL:
  • Gemfibrozil: 600 mg twice daily (30 minutes before morning and evening meals) 2
  • Micronized fenofibrate: 54-160 mg once daily 2
  • Fish oils and niacin are alternative agents but less preferred 2

Critical Monitoring Requirements

• For ACE inhibitors/ARBs: Monitor serum creatinine, eGFR, and potassium at baseline, within 7-14 days after initiation, and at least annually 2, 3

• For statins: Monitor for hepatic and skeletal muscle toxicity 2

Important Contraindications

• Never combine ACE inhibitor with ARB - increases adverse events (hyperkalemia, syncope, acute kidney injury) without cardiovascular benefit 2, 3

• Avoid statin-fibrate combinations except with extreme caution due to myopathy risk; if necessary, use pravastatin with fenofibrate 2

• Niacin should be avoided as first-line in patients with lipoatrophy or receiving HIV protease inhibitors 2