Recommended Antihypertensive Agent

Lisinopril (option c) is the recommended first-line antihypertensive for this patient with type 2 diabetes, hypertension, and stage 1 obesity.

Rationale for ACE Inhibitor Selection

ACE inhibitors are the preferred initial agent for diabetic patients with hypertension and obesity because they provide:

Renal protection that is critical in diabetes, even before albuminuria develops 1, 2
Weight neutrality without metabolic harm—crucial given her BMI of 35 2
Improved insulin sensitivity without worsening glucose control 2
Superior cardiovascular outcomes including 22% reduction in myocardial infarction, 33% reduction in stroke, and 37% reduction in cardiovascular death in diabetic patients 2

While metabolically neutral and weight-neutral, calcium channel blockers are recommended as second-line therapy to be added if blood pressure remains uncontrolled on an ACE inhibitor/ARB 1, 2
The ABCD trial showed significantly higher myocardial infarction rates with nisoldipine compared to enalapril (25 vs 5 events, p=0.001) in hypertensive type 2 diabetics 1, 3
The FACET trial demonstrated fewer combined cardiovascular events with fosinopril versus amlodipine (RR 0.49) despite similar blood pressure control 1

Thiazide diuretics cause dose-dependent insulin resistance, worsen glucose control, and worsen dyslipidemia 2
While ALLHAT showed no difference in primary outcomes between chlorthalidone and lisinopril, thiazides should be avoided as first-line in obese diabetic patients at high risk for metabolic syndrome 2
Her HbA1c of 6.6% indicates borderline control that could worsen with thiazide therapy 2

Beta-blockers promote weight gain, prevent weight loss, decrease metabolic rate, and worsen insulin resistance 2
They increase the risk of new-onset diabetes and are not recommended as first-line therapy except in patients with heart failure or prior myocardial infarction 1, 2, 4
This patient has neither indication 2

Initial dosing strategy:

Start lisinopril 10 mg daily, as blood pressure of 138/86 mmHg falls in the 140-159/90-99 mmHg range where monotherapy is appropriate 1, 5
Target blood pressure is <130/80 mmHg for diabetic patients 1

Monitoring requirements:

Check serum creatinine/eGFR and potassium 7-14 days after initiation 5, 2
Assess for albuminuria if not already done, as presence strengthens the indication for ACE inhibitor therapy 1, 5, 2
Monitor blood pressure every 2-4 weeks during titration 1

Titration plan:

If blood pressure remains >130/80 mmHg after 2-4 weeks, increase lisinopril to 20 mg daily 6
Maximum dose is 40 mg daily for hypertension 6
If target not achieved on maximum ACE inhibitor dose, add amlodipine (dihydropyridine calcium channel blocker) as second agent 1, 2

This patient requires immediate contraception counseling given:

Inconsistent barrier contraception use with her partner
ACE inhibitors are teratogenic and absolutely contraindicated in pregnancy 1
She must use reliable contraception or switch to an alternative antihypertensive if pregnancy is desired

Never combine ACE inhibitor with ARB or direct renin inhibitor—this increases adverse events (hyperkalemia, syncope, acute kidney injury) without added benefit 1, 5
Do not start with beta-blocker or thiazide diuretic first-line in obese diabetic patients due to metabolic harm 2
Do not delay treatment—her blood pressure of 138/86 mmHg warrants prompt pharmacologic therapy in addition to lifestyle modification 1
Monitor for hyperkalemia, especially given her baseline potassium of 3.8 mEq/L is on the lower end of normal 5