What are the guidelines for blood pressure (BP) medication?

Blood Pressure Medication Guidelines

Blood Pressure Classification and Treatment Thresholds

For most adults, initiate antihypertensive medication when blood pressure is ≥140/90 mmHg, with thiazide-type diuretics as first-line therapy for patients without compelling indications. 1

BP Categories and Treatment Approach

• Normal BP (≤120/80 mmHg): Encourage lifestyle modifications only, no pharmacologic therapy 1

• Prehypertension (130-139/80-89 mmHg): Implement lifestyle modifications; reserve drug therapy only for patients with compelling indications such as diabetes, chronic kidney disease, or established cardiovascular disease 1

• Stage 1 Hypertension (140-159/90-99 mmHg): Initiate thiazide-type diuretics for most patients; may consider ACE inhibitor, ARB, beta blocker, or calcium channel blocker as alternatives 1

• Stage 2 Hypertension (≥160/100 mmHg): Start with 2-drug combination therapy, usually thiazide-type diuretic plus ACE inhibitor, ARB, beta blocker, or calcium channel blocker 1

Blood Pressure Treatment Goals

Target blood pressure should be <140/90 mmHg for most adults, with more aggressive targets of <130/80 mmHg for patients with diabetes or chronic kidney disease. 1, 2

• For adults <65 years: Target SBP/DBP <130/80 mmHg 2
• For adults ≥65 years: Target SBP <130 mmHg 2
• For patients with diabetes or chronic kidney disease: Target <130/80 mmHg 1

First-Line Medication Classes

Thiazide-Type Diuretics (Preferred Initial Therapy)

Thiazide-type diuretics should be used as initial therapy for most patients with hypertension, either alone or in combination, as they reduce cardiovascular complications, enhance efficacy of multidrug regimens, and are more affordable than other agents. 1

• Hydrochlorothiazide: 12.5-25 mg once daily 3, 4
• Chlorthalidone: 12.5-25 mg once daily (preferred due to longer duration of action) 3

ACE Inhibitors and ARBs

• Particularly beneficial for patients with chronic kidney disease, heart failure, or coronary artery disease 3
• Lisinopril dosing: Start 10 mg once daily, usual range 20-40 mg daily, maximum 80 mg daily 4
• When combined with diuretics, start lisinopril at 5 mg once daily 4
• Monitor serum potassium and creatinine 2-4 weeks after initiation 3

Calcium Channel Blockers

• Amlodipine provides complementary vasodilation mechanism 3
• For Black patients, calcium channel blockers are preferred as initial therapy over ACE inhibitors or ARBs 3
• Monitor for peripheral edema, which may be attenuated by adding an ACE inhibitor or ARB 3

Combination Therapy Algorithm

Two-Drug Combinations

When blood pressure remains uncontrolled on monotherapy, add a second agent from a different class rather than maximizing the dose of the first agent. 3

• ACE inhibitor/ARB + Calcium channel blocker: Provides complementary mechanisms, particularly effective for patients with diabetes, chronic kidney disease, or heart failure 3

• Calcium channel blocker + Thiazide diuretic: Especially effective for Black patients, elderly patients, or those with volume-dependent hypertension 3

• ACE inhibitor/ARB + Thiazide diuretic: Standard combination with proven cardiovascular benefit 3

Three-Drug Combinations (Triple Therapy)

For uncontrolled hypertension on two medications, add a third agent to achieve the guideline-recommended triple therapy of ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic. 3

• This combination targets three complementary mechanisms: renin-angiotensin system blockade, vasodilation, and volume reduction 3
• Optimize doses of existing medications before adding the third agent 3
• Reassess blood pressure within 2-4 weeks after adding the third agent 3

Resistant Hypertension (Four-Drug Therapy)

If blood pressure remains uncontrolled despite optimized triple therapy, add spironolactone 25-50 mg daily as the preferred fourth-line agent. 3

• Spironolactone addresses occult volume expansion and aldosterone excess that commonly underlies treatment resistance 3
• Monitor potassium closely when adding spironolactone to an ACE inhibitor or ARB due to significant hyperkalemia risk 3
• Alternative fourth-line agents if spironolactone is contraindicated include amiloride, doxazosin, or eplerenone 3

Critical Pitfalls to Avoid

• Never combine ACE inhibitors with ARBs: This increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 3

• Do not add beta-blockers as third-line agents unless there are compelling indications such as angina, post-myocardial infarction, heart failure with reduced ejection fraction, or need for heart rate control 3

• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in patients with heart failure or left ventricular dysfunction 3

• Do not delay treatment intensification in patients with stage 2 hypertension, as prompt action reduces cardiovascular risk 3

• Always verify medication adherence before adding additional agents, as non-adherence is the most common cause of apparent treatment resistance 3

Lifestyle Modifications (Essential Foundation)

All patients with hypertension or prehypertension should implement lifestyle modifications, which provide additive blood pressure reductions of 10-20 mmHg and enhance the efficacy of pharmacologic therapy. 2, 5, 6

• Sodium restriction: Limit intake to <2 g/day 3, 2
• Weight loss: Target BMI 20-25 kg/m² 3
• DASH diet: Emphasize fruits, vegetables, low-fat dairy products, reduced saturated fat and cholesterol 2, 6
• Physical activity: Regular aerobic exercise 2, 6
• Alcohol moderation: Limit to <100 g/week 3
• Potassium supplementation: Increase dietary potassium intake 2, 6

Monitoring and Follow-Up

• Reassess blood pressure within 2-4 weeks after any medication adjustment 3
• Goal is to achieve target blood pressure within 3 months of initiating or modifying therapy 3
• Check serum potassium and creatinine when initiating or uptitrating ACE inhibitors, ARBs, or diuretics 3
• Consider home blood pressure monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) to confirm sustained hypertension 3
• Refer to hypertension specialist if blood pressure remains ≥160/100 mmHg despite four-drug therapy at optimal doses 3