What is the best first-line antihypertensive for a 34-year-old patient with alcohol use disorder (AUD), autonomic dysfunction, and mild hypertension, without other medical issues?

From the Guidelines

For a 34-year-old alcohol disorder patient with autonomic dysfunction, mild hypertension related to alcohol use, and bilateral foot swelling, an ACE inhibitor like lisinopril would be the best first-line antihypertensive treatment. This recommendation is based on the most recent and highest quality study available, which suggests that ACE inhibitors are a suitable choice for patients with hypertension, particularly those without compelling indications for other specific drugs 1. Start with lisinopril 10 mg once daily, which can be titrated up to 40 mg daily if needed for blood pressure control. ACE inhibitors are particularly appropriate in this case because they don't worsen autonomic dysfunction, don't cause fluid retention (unlike amlodipine), and may offer additional benefits for alcohol-related organ damage. They work by blocking the renin-angiotensin-aldosterone system, reducing peripheral vascular resistance without significantly affecting heart rate. Some key points to consider when treating this patient include:

• Monitoring for potential side effects including cough, dizziness, and rarely angioedema
• Counseling the patient on alcohol reduction or cessation, as this would address the underlying cause of hypertension
• Regular follow-up within 2-4 weeks to assess efficacy and tolerability of the medication
• Targeting a blood pressure goal of less than 130/80 mm Hg, as recommended by recent guidelines 1 It's also important to note that the patient's lifestyle changes, such as regular exercise and a balanced diet, should be encouraged to help manage their hypertension and overall health.

From the FDA Drug Label

The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure A starting dose of 25 mg is recommended for patients with possible intravascular depletion (e.g., on diuretic therapy).

The best first-line antihypertensive for a young alcohol disorder patient with no other medical issues, autonomic dysfunction, and mild hypertension is losartan.

• The patient's age and lack of other medical issues make losartan a suitable choice.
• Losartan has been shown to be effective in reducing blood pressure in various patient populations, including those with mild hypertension.
• The recommended starting dose is 50 mg once daily, which can be adjusted as needed to control blood pressure.
• Since the patient is sedentary and has feet swelling bilaterally, losartan may be a better option than amlodipine, which can cause peripheral edema. 2 2

From the Research

Autonomic Dysfunction and Hypertension in Alcohol Disorder Patients

• Autonomic dysfunction is a known consequence of chronic and excessive alcohol consumption, affecting 16-73% of chronic alcohol abusers 3.
• The most important risk factor for autonomic dysfunction is the total lifetime dose of ethanol.

First-Line Antihypertensive Treatment

• For patients with alcohol-induced hypertension, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor blockers (ARBs) are recommended as first-line antihypertensive treatment due to their antioxidant activity 4, 5.
• These medications have been shown to be effective in treating hypertension in patients with alcohol use disorder.

Considerations for the Patient

• Given the patient's sedentary lifestyle and bilateral feet swelling, ACE inhibitors or ARBs may be a better option than calcium channel blockers like amlodipine.
• The patient's autonomic dysfunction and mild hypertension should be managed concurrently, with a focus on reducing alcohol intake and increasing physical activity 5, 6.
• Abstinence from alcohol is the first step in managing hypertension, and pharmacologic treatment should be withheld until after 2 to 4 weeks of abstinence from alcohol 4.