What are the prescription templates for hypertension management and treatment, including all possible case scenarios?

Hypertension Management: Comprehensive Prescription Templates

General Approach to All Hypertensive Patients

All patients with confirmed hypertension should receive both lifestyle modifications and pharmacological therapy simultaneously when BP ≥140/90 mmHg, with the specific drug regimen tailored to comorbidities and BP severity. 1

---

Template 1: Uncomplicated Hypertension (No Comorbidities)

Patient Profile

• BP ≥140/90 mmHg confirmed on multiple visits 2
• No diabetes, CKD, CVD, or other compelling indications 1
• Age <65 years 2

Prescription Template

Initial Therapy (BP 140-159/90-99 mmHg):

Rx: Lisinopril 10 mg PO daily
OR
Rx: Losartan 50 mg PO daily
PLUS
Rx: Amlodipine 5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

1, 3

Lifestyle Modifications (mandatory concurrent prescription):

• Sodium restriction: <1500 mg/day (or reduce by ≥1000 mg/day) 2
• DASH diet: increase fruits, vegetables, whole grains, low-fat dairy 2, 1
• Potassium supplementation: 3500-5000 mg/day through diet 2
• Weight loss: target ≥1 kg if overweight/obese 2
• Physical activity: 90-150 minutes/week aerobic exercise 2
• Alcohol: ≤2 drinks/day (men), ≤1 drink/day (women) 2

Escalation if BP Not Controlled at 4 Weeks:

Rx: Lisinopril 20 mg PO daily
PLUS
Rx: Amlodipine 10 mg PO daily
PLUS
Rx: Chlorthalidone 12.5 mg PO daily

Dispense: 30-day supply
Refills: 2
Follow-up: 4 weeks

1, 4

---

Template 2: Severe Hypertension (≥160/100 mmHg)

Patient Profile

• BP ≥160/100 mmHg 2
• Immediate pharmacological intervention required 1

Prescription Template

Initial Combination Therapy (Start Immediately):

Rx: Lisinopril 10 mg + Amlodipine 5 mg (single-pill combination) PO daily
PLUS
Rx: Chlorthalidone 12.5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 1
Follow-up: 2 weeks (urgent)

1, 4

If BP >220/120 mmHg or with impending complications:

• Immediate emergency department referral 2, 1
• Do not attempt outpatient titration 2

---

Template 3: Hypertension with Diabetes

Patient Profile

• BP ≥130/80 mmHg 2
• Confirmed diabetes mellitus 2
• Target BP: <130/80 mmHg 2

Prescription Template

Initial Therapy:

Rx: Lisinopril 10 mg PO daily
OR
Rx: Losartan 100 mg PO daily
PLUS
Rx: Amlodipine 5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

Labs: Check serum creatinine and potassium in 1-2 weeks

2, 3

Additional Mandatory Therapy:

Rx: Atorvastatin 40 mg PO daily
(if LDL-C >100 mg/dL in uncomplicated diabetes or >70 mg/dL with target organ damage)

Dispense: 30-day supply
Refills: 11

2

Glucose Management:

• Target fasting glucose <126 mg/dL or HbA1c <7% 2

---

Template 4: Hypertension with Chronic Kidney Disease (CKD)

Patient Profile

• BP ≥130/80 mmHg 2
• eGFR <60 mL/min/1.73m² or albuminuria present 2
• Target BP: <130/80 mmHg 2

Prescription Template

Initial Therapy:

Rx: Lisinopril 10 mg PO daily
OR
Rx: Losartan 50 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 1-2 weeks

Labs: Check serum creatinine and potassium in 1 week

2

Critical Monitoring:

• Acceptable creatinine increase: up to 30% from baseline 2
• Hold medication if potassium >5.5 mEq/L 2
• If BP not controlled, add amlodipine 5 mg daily before increasing ACE-I/ARB dose 2

Escalation:

Rx: Lisinopril 20 mg PO daily
PLUS
Rx: Amlodipine 10 mg PO daily
PLUS
Rx: Chlorthalidone 25 mg PO daily (if eGFR >30)
OR
Rx: Furosemide 40 mg PO daily (if eGFR <30)

Follow-up: 2 weeks
Labs: Recheck creatinine and potassium

2

---

Template 5: Hypertension with Heart Failure (Reduced Ejection Fraction)

Patient Profile

• BP ≥130/80 mmHg 2
• LVEF <40% 2
• Symptomatic heart failure 2

Prescription Template

Guideline-Directed Medical Therapy (GDMT):

Rx: Carvedilol 3.125 mg PO twice daily
(titrate to target dose 25 mg twice daily over 4-8 weeks)

PLUS

Rx: Lisinopril 5 mg PO daily
(titrate to target dose 20-40 mg daily)

PLUS

Rx: Spironolactone 25 mg PO daily
(if NYHA Class II-IV and eGFR >30)

PLUS

Rx: Furosemide 20-40 mg PO daily
(for volume overload)

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2 weeks

Labs: Check potassium and creatinine weekly during titration

2

Avoid:

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) 2

---

Template 6: Hypertension with Heart Failure (Preserved Ejection Fraction)

Patient Profile

• BP ≥130/80 mmHg 2
• LVEF ≥50% 2
• Symptomatic heart failure 2

Prescription Template

Initial Therapy:

Rx: Chlorthalidone 12.5 mg PO daily
(for volume overload)

PLUS

Rx: Lisinopril 10 mg PO daily
(for incremental BP control)

PLUS

Rx: Carvedilol 6.25 mg PO twice daily
(for incremental BP control)

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

2

---

Template 7: Hypertension with Coronary Artery Disease

Patient Profile

• BP ≥130/80 mmHg 2
• History of MI, ACS, or stable angina 2

Prescription Template

Post-MI or ACS:

Rx: Metoprolol succinate 25 mg PO daily
(titrate to 200 mg daily or maximum tolerated dose)

PLUS

Rx: Lisinopril 10 mg PO daily
(titrate to 40 mg daily)

PLUS

Rx: Aspirin 81 mg PO daily

PLUS

Rx: Atorvastatin 80 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 11
Follow-up: 2 weeks

2

Stable Angina:

Rx: Metoprolol succinate 50 mg PO daily

PLUS

Rx: Amlodipine 5 mg PO daily
(for additional BP control)

PLUS

Rx: Lisinopril 10 mg PO daily

Target BP: <130/80 mmHg

2

---

Template 8: Hypertension with Atrial Fibrillation

Patient Profile

• BP ≥130/80 mmHg 2
• History of atrial fibrillation 2

Prescription Template

Initial Therapy:

Rx: Losartan 50 mg PO daily
(ARBs may reduce AF recurrence)

PLUS

Rx: Amlodipine 5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

2

Rate Control (if needed):

Add: Metoprolol tartrate 25 mg PO twice daily
OR
Add: Diltiazem 120 mg PO daily

2

---

Template 9: Hypertension Post-Stroke (Secondary Prevention)

Patient Profile

• BP ≥140/90 mmHg 2
• History of ischemic stroke or TIA 2
• Start therapy few days post-event 2

Prescription Template

Initial Therapy:

Rx: Chlorthalidone 12.5 mg PO daily

PLUS

Rx: Lisinopril 10 mg PO daily
OR
Rx: Losartan 50 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

2

Alternative Combination:

Rx: Chlorthalidone 12.5 mg + Lisinopril 10 mg (combination pill) PO daily

2

---

Template 10: Hypertension in Black Patients

Patient Profile

• BP ≥140/90 mmHg 1
• Self-identified Black race 1, 3

Prescription Template

Initial Therapy:

Rx: Amlodipine 5 mg PO daily

PLUS

Rx: Chlorthalidone 12.5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

1, 3

Alternative (if additional BP lowering needed):

Rx: Losartan 50 mg PO daily
PLUS
Rx: Amlodipine 10 mg PO daily

OR

Rx: Amlodipine 10 mg PO daily
PLUS
Rx: Chlorthalidone 25 mg PO daily

1

Note: ACE inhibitors and ARBs are less effective as monotherapy in Black patients but effective in combination 3

---

Template 11: Hypertension in Young Adults (<40 Years)

Patient Profile

• BP ≥140/90 mmHg confirmed 5
• Age <40 years 5
• Mandatory secondary hypertension workup 5

Prescription Template

Initial Therapy (after excluding secondary causes):

Rx: Lisinopril 10 mg PO daily
OR
Rx: Losartan 50 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

Labs: Serum creatinine, potassium, lipid panel, HbA1c
Additional workup: Renal ultrasound, plasma renin/aldosterone ratio, sleep study if obese

5

Escalation:

Rx: Lisinopril 20 mg PO daily
PLUS
Rx: Amlodipine 5 mg PO daily

Follow-up: 2-4 weeks

5

---

Template 12: Hypertension in Elderly (≥65 Years)

Patient Profile

• BP ≥140/90 mmHg 2
• Age ≥65 years 2
• Target SBP: <130 mmHg (if tolerated) 2, 4

Prescription Template

Initial Therapy (start low, go slow):

Rx: Amlodipine 2.5 mg PO daily

PLUS

Rx: Chlorthalidone 6.25 mg PO daily

Target BP: <130/80 mmHg (if tolerated)
Minimum acceptable: <150/90 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

Monitor: Orthostatic hypotension, falls, electrolytes

2

Escalation (gradual titration):

Rx: Amlodipine 5 mg PO daily
PLUS
Rx: Chlorthalidone 12.5 mg PO daily
PLUS
Rx: Lisinopril 5 mg PO daily (if tolerated)

Follow-up: 4 weeks

2

---

Template 13: Resistant Hypertension (Uncontrolled on 3 Drugs)

Patient Profile

• BP ≥130/80 mmHg despite 3 drugs including diuretic 2
• Confirmed medication adherence 2

Prescription Template

Optimized Triple Therapy:

Rx: Lisinopril 40 mg PO daily
OR
Rx: Losartan 100 mg PO daily

PLUS

Rx: Amlodipine 10 mg PO daily

PLUS

Rx: Chlorthalidone 25 mg PO daily

Dispense: 30-day supply
Refills: 1
Follow-up: 2-4 weeks

2

Fourth-Line Agent:

Add: Spironolactone 25 mg PO daily
(if potassium <4.5 mEq/L and eGFR >30)

Labs: Check potassium and creatinine in 1 week, then monthly

2

Alternative Fourth-Line Agents:

Add: Doxazosin 1 mg PO at bedtime
(titrate to 8 mg daily)

OR

Add: Hydralazine 25 mg PO three times daily
(titrate to 100 mg three times daily)

OR

Add: Clonidine 0.1 mg PO twice daily
(titrate to 0.3 mg twice daily)

6

Mandatory Actions:

• Refer to hypertension specialist 5
• Screen for secondary hypertension 2
• Confirm adherence with pill counts or pharmacy records 2

---

Template 14: Hypertension with Aortic Disease

Patient Profile

• BP ≥130/80 mmHg 2
• Thoracic aortic aneurysm or dissection history 2

Prescription Template

Initial Therapy:

Rx: Metoprolol succinate 50 mg PO daily
(titrate to maximum tolerated dose, target HR 60-70 bpm)

PLUS

Rx: Lisinopril 10 mg PO daily

Target BP: <120/80 mmHg (strict control)
Dispense: 30-day supply
Refills: 2
Follow-up: 2 weeks

2

---

Template 15: Hypertension with Peripheral Arterial Disease

Patient Profile

• BP ≥130/80 mmHg 2
• Confirmed PAD (ABI <0.9) 2

Prescription Template

Initial Therapy:

Rx: Lisinopril 10 mg PO daily

PLUS

Rx: Amlodipine 5 mg PO daily

PLUS

Rx: Aspirin 81 mg PO daily

PLUS

Rx: Atorvastatin 40 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 11
Follow-up: 2-4 weeks

2

---

Template 16: Hypertension Post-Kidney Transplant

Patient Profile

• BP ≥160/90 mmHg (first month post-transplant) 2
• BP ≥130/80 mmHg (after first month) 2
• Kidney transplant recipient 2

Prescription Template

Initial Therapy (First Month Post-Transplant):

Rx: Amlodipine 5 mg PO daily
(calcium antagonists improve graft survival and GFR)

Target BP: <160/90 mmHg (avoid hypotension-induced graft thrombosis)
Dispense: 30-day supply
Refills: 1
Follow-up: 1-2 weeks

Coordinate with transplant team

2

After First Month:

Rx: Amlodipine 10 mg PO daily

PLUS

Rx: Lisinopril 5 mg PO daily
(use ACE-I with caution, close monitoring)

Target BP: <130/80 mmHg
Labs: Weekly creatinine and potassium initially

2

---

Template 17: Hypertension with Asymptomatic Aortic Stenosis

Patient Profile

• BP ≥130/80 mmHg 2
• Moderate-severe aortic stenosis, asymptomatic 2

Prescription Template

Initial Therapy (start low, titrate slowly):

Rx: Lisinopril 2.5 mg PO daily
(initiate with low doses, up-titrate slowly)

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 1
Follow-up: 1-2 weeks

Monitor: Symptoms of syncope, angina, dyspnea

2

Escalation:

Rx: Lisinopril 5 mg PO daily
PLUS
Rx: Amlodipine 2.5 mg PO daily

Titrate every 2-4 weeks based on tolerance

2

---

Template 18: Hypertension with Aortic Insufficiency

Patient Profile

• BP ≥130/80 mmHg 2
• Aortic regurgitation 2

Prescription Template

Initial Therapy:

Rx: Lisinopril 10 mg PO daily

PLUS

Rx: Amlodipine 5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

2

Avoid:

• Beta blockers (slow heart rate, worsen regurgitation) 2
• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) 2

---

Template 19: White Coat Hypertension

Patient Profile

• Office BP ≥140/90 mmHg 2
• Home BP <135/85 mmHg or daytime ambulatory BP <135/85 mmHg 2

Management Template

No Pharmacological Therapy Initially:

Lifestyle Modifications:
- Sodium restriction: <1500 mg/day
- DASH diet
- Weight loss if BMI >25
- Physical activity: 150 min/week
- Alcohol moderation

Home BP Monitoring:
- Measure BP twice daily (morning and evening)
- Record for 7 days before each visit
- Use validated automated device

Follow-up: Every 6-12 months
Annual transition rate to sustained hypertension: 1-5%

2

Initiate Therapy If:

• Home BP rises to ≥135/85 mmHg 2
• 10-year CVD risk ≥20% 2
• Target organ damage develops 2

---

Template 20: Elevated Blood Pressure (130-139/80-89 mmHg)

Patient Profile

• BP 130-139/80-89 mmHg 2, 1
• No diabetes, CKD, or CVD 1
• 10-year CVD risk <20% 1

Management Template

Lifestyle Modifications Only (3-6 Month Trial):

Lifestyle Prescription:
- Sodium restriction: <1500 mg/day
- Potassium supplementation: 3500-5000 mg/day (dietary)
- Weight loss: target ≥1 kg
- DASH diet
- Physical activity: 90-150 min/week
- Alcohol: ≤2 drinks/day (men), ≤1/day (women)

Follow-up: Every 3-6 months
Recheck BP at each visit

2, 1

Initiate Pharmacotherapy If:

• BP rises to ≥140/90 mmHg 1
• 10-year CVD risk ≥20% (start immediately) 1
• Diabetes, CKD, or CVD develops 1

---

Template 21: Hypertension with High Cardiovascular Risk (No Comorbidities)

Patient Profile

• BP 130-139/80-89 mmHg 1
• 10-year CVD risk ≥20% (ASCVD calculator) 1
• No diabetes, CKD, or established CVD 1

Prescription Template

Immediate Pharmacotherapy:

Rx: Lisinopril 10 mg PO daily

PLUS

Rx: Amlodipine 5 mg PO daily

PLUS

Rx: Atorvastatin 40 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

1

---

Template 22: Hypertension with Metabolic Syndrome

Patient Profile

• BP ≥130/80 mmHg 2
• Metabolic syndrome (≥3 criteria: waist circumference >40" men/>35" women, triglycerides ≥150 mg/dL, HDL <40 men/<50 women, fasting glucose ≥100 mg/dL, BP ≥130/85 mmHg) 2

Prescription Template

Initial Therapy:

Rx: Lisinopril 10 mg PO daily
OR
Rx: Losartan 50 mg PO daily

PLUS

Rx: Amlodipine 5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

Labs: Fasting lipid panel, HbA1c, liver function tests

2

Lifestyle Modifications (Critical):

• Weight loss: target 5-10% body weight 2
• Mediterranean or DASH diet 2
• Physical activity: 150 min/week 2

Additional Therapy Based on Risk:

Add: Atorvastatin 20-40 mg PO daily
(if LDL-C >100 mg/dL or 10-year CVD risk ≥20%)

Add: Metformin 500 mg PO twice daily
(if fasting glucose 100-125 mg/dL for diabetes prevention)

2

---

Template 23: Hypertension with Rheumatoid Arthritis

Patient Profile

• BP ≥130/80 mmHg 2
• Confirmed rheumatoid arthritis or other inflammatory rheumatic disease 2
• Increased cardiovascular risk (add 1 step to risk calculator) 2

Prescription Template

Initial Therapy:

Rx: Lisinopril 10 mg PO daily
(evidence of overactive RAAS in IRD)

PLUS

Rx: Amlodipine 5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

2

Additional Management:

• Optimize disease-modifying antirheumatic drugs (DMARDs) to reduce inflammation 2
• Avoid high-dose NSAIDs (worsen BP control) 2
• Consider statin therapy (calculate CVD risk with 1-step increase) 2

---

Template 24: Hypertension with Depression/Psychiatric Disease

Patient Profile

• BP ≥130/80 mmHg 2
• Major depression or other psychiatric disorder 2
• Increased cardiovascular risk 2

Prescription Template

Initial Therapy:

Rx: Lisinopril 10 mg PO daily

PLUS

Rx: Amlodipine 5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

Coordinate with psychiatry for medication interactions

2

Avoid:

• Beta blockers (may worsen depression) 2

Monitor:

• Medication adherence (often poor in psychiatric patients) 2
• Drug interactions with psychotropic medications 2

---

Template 25: Hypertension with HIV/AIDS

Patient Profile

• BP ≥130/80 mmHg 2
• HIV infection on antiretroviral therapy 2

Prescription Template

Initial Therapy:

Rx: Lisinopril 10 mg PO daily

PLUS

Rx: Chlorthalidone 12.5 mg PO daily

Target BP: <130/80 mmHg
Dispense: 30-day supply
Refills: 2
Follow-up: 2-4 weeks

Coordinate with infectious disease for drug interactions

2

Caution:

• Calcium channel blockers may interact with most antiretroviral therapies 2
• If CCB needed, use with caution and monitor for drug interactions 2

---

Critical Monitoring Parameters (All Patients)

Laboratory Monitoring Schedule

Baseline (before initiating therapy):

• Serum creatinine and eGFR 2
• Serum potassium 2
• Fasting lipid panel 2
• Fasting glucose or HbA1c 2
• Urinalysis 2
• ECG (if CVD risk factors present) 2

After Initiating ACE-I/ARB:

• Recheck creatinine and potassium in 1-2 weeks 5
• Acceptable creatinine increase: up to 30% from baseline 2
• Hold medication if potassium >5.5 mEq/L 2

After Initiating Diuretics:

• Recheck electrolytes in 2-4 weeks 2
• Monitor for hypokalemia, hyponatremia, hyperuricemia 2

Ongoing Monitoring:

• BP check every 3-6 months once controlled 2
• Annual labs: creatinine, potassium, lipids, glucose 2

---

Common Pitfalls to Avoid

Clinical Inertia:

• Do not delay treatment in high-risk patients (diabetes, CKD, CVD, 10-year risk ≥20%) 1
• Initiate combination therapy immediately for BP ≥140/90 mmHg 1
• Avoid prolonged monotherapy titration when combination therapy is indicated 1

Inadequate Dosing:

• Titrate to maximum tolerated doses before adding additional agents 2
• Lisinopril effective doses: 10-40 mg daily 3
• Do not use subtherapeutic doses (e.g., lisinopril 5 mg as maintenance) 3

Wrong Drug Combinations:

• Never combine ACE-I + ARB (increased adverse events, no benefit) 2
• Avoid beta blockers + non-DHP CCB (excessive bradycardia) 2
• Avoid beta blockers in aortic insufficiency 2

Monitoring Failures:

• Always check creatinine and potassium 1-2 weeks after starting ACE-I/ARB 5
• Do not continue ACE-I/ARB if creatinine increases >30% 2
• Do not ignore orthostatic hypotension in elderly patients 2

Lifestyle Modification Neglect:

• Always prescribe lifestyle modifications concurrently with medications 2, 1
• Lifestyle changes enhance drug efficacy and may reduce medication burden 2

---

Follow-Up Schedule

Newly Diagnosed Hypertension:

• Follow-up in 2-4 weeks after initiating therapy 1
• Monthly visits for dose titration until BP controlled 2
• Once controlled: every 3-6 months 2

Resistant Hypertension:

• Follow-up every 2-4 weeks during optimization 2
• Refer to specialist if uncontrolled on 3 drugs 5

Stable Controlled Hypertension:

• Follow-up every 3-6 months 2
• Annual comprehensive assessment 2

Home BP Monitoring:

• Measure twice daily (morning and evening) 1
• Record for 7 days before each visit 1
• Home BP targets: approximately 10/5 mmHg lower than office targets 2