What is the best medication for lowering diastolic blood pressure (DBP)?

From the Guidelines

The most effective medications for lowering diastolic blood pressure are typically diuretics, ACE inhibitors, ARBs, and calcium channel blockers, with thiazide diuretics and calcium-channel blockers being the preferred options for first-line therapy in most adults, as recommended by the 2024 ESC guidelines 1.

Key Medications for Diastolic Hypertension

• Thiazide diuretics like hydrochlorothiazide (12.5-25mg daily) are often recommended as first-line treatment due to their effectiveness and low cost.
• ACE inhibitors such as lisinopril (10-40mg daily) or ARBs like losartan (50-100mg daily) work by relaxing blood vessels and are particularly effective for diastolic hypertension.
• Calcium channel blockers like amlodipine (5-10mg daily) are also excellent options, especially for older patients or those with isolated diastolic hypertension.

Considerations for Treatment

• The choice of medication should be individualized based on age, race, comorbidities, and potential side effects, as noted in the 2018 American College of Cardiology/American Heart Association hypertension guideline 1.
• Lifestyle modifications including reducing sodium intake, maintaining healthy weight, regular exercise, limiting alcohol, and managing stress should accompany medication therapy for optimal results.

Recent Guideline Recommendations

• The 2024 ESC guidelines recommend combination BP-lowering treatment as initial therapy for most patients with confirmed hypertension, with preferred combinations being a RAS blocker with a dihydropyridine CCB or diuretic 1.
• Fixed-dose single-pill combination treatment is recommended for patients receiving combination BP-lowering treatment, and adding spironolactone should be considered if BP is not controlled with a three-drug combination 1.

From the FDA Drug Label

Lisinopril demonstrated superior reductions of systolic and diastolic compared to hydrochlorothiazide in a population that was 75% Caucasian Lisinopril was approximately equivalent to atenolol and metoprolol in reducing diastolic blood pressure, and had somewhat greater effects on systolic blood pressure. In this study, lisinopril was given either as tablets or in a suspension for those children and infants who were unable to swallow tablets or who required a lower dose than is available in tablet form The dose-dependent antihypertensive effect of lisinopril was consistent across several demographic subgroups: age, Tanner stage, gender, and race

The best medication for lowering diastolic blood pressure is lisinopril, as it has been shown to be effective in reducing diastolic blood pressure in various studies, including a comparison with other medications such as hydrochlorothiazide, atenolol, and metoprolol 2.

• Lisinopril has been found to be approximately equivalent to atenolol and metoprolol in reducing diastolic blood pressure.
• The medication has a dose-dependent effect, with higher doses resulting in greater reductions in blood pressure.
• Lisinopril is effective across various demographic subgroups, including different ages, genders, and races.

From the Research

Medications for Lowering Diastolic Blood Pressure

• Amlodipine and valsartan combination has been shown to be effective in lowering diastolic blood pressure, with significant reductions from baseline in MSDBP (-28.6 [7.7] mm Hg) 3.
• Lisinopril plus hydrochlorothiazide combination also achieved significant reductions in MSDBP (-27.6 [8.6] mm Hg) 3.
• Nifedipine GITS and amlodipine have been compared in patients with mild-to-moderate essential hypertension, with both treatments showing comparable efficacy in lowering diastolic blood pressure (mean decrease of 16.4 +/- 7.0 and 17.5 +/- 6.9 mmHg, respectively) 4.
• Calcium channel blockers, including amlodipine, have been found to effectively lower blood pressure, especially in combination with other drugs 5.
• Amlodipine has unique characteristics that distinguish it from other calcium channel blockers, including low renal clearance and long half-life, allowing it to sustain its anti-hypertensive effect for more than 24 hours 6.
• The combination of valsartan, amlodipine, and hydrochlorothiazide has been shown to be effective in blood pressure control, with the addition of hydrochlorothiazide enhancing the effect of the other two agents 7.

Comparison of Medications

• Amlodipine and nifedipine GITS have been compared, with both showing comparable efficacy and safety in patients with mild-to-moderate essential hypertension 4.
• The combination of amlodipine and valsartan has been compared to lisinopril plus hydrochlorothiazide, with both combinations showing significant reductions in diastolic blood pressure 3.
• Amlodipine has been found to be a wise choice for older adults due to its ability to control blood pressure and protect against stroke and myocardial infarction 6.

Safety and Tolerability

• Amlodipine and valsartan combination has been found to be generally well tolerated, with adverse events being mild to moderate in severity 3.
• Nifedipine GITS and amlodipine have been found to be well tolerated, with the overall incidence of adverse events being 7.9% and 10.1%, respectively 4.
• Amlodipine has been found to have side effects including edema, palpitations, dizziness, and flushing, which are more common with the higher dose of 10 mg 6.