From the Guidelines
The first-line antihypertensive medications should include ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics (thiazides and thiazide-like drugs), as they have demonstrated the most effective reduction of BP and CVD events, according to the 2024 ESC guidelines 1.
Key Considerations
- The choice of first-line antihypertensive medication depends on patient characteristics, such as the presence of diabetes or chronic kidney disease.
- ACE inhibitors or ARBs are preferred for patients with diabetes or chronic kidney disease, while calcium channel blockers may be better for elderly patients or those of African descent.
- Thiazide diuretics are often cost-effective and work well for many patients.
Recommended Medications
- Thiazide diuretics (e.g., hydrochlorothiazide 12.5-25mg daily or chlorthalidone 12.5-25mg daily)
- Calcium channel blockers (e.g., amlodipine 5-10mg daily)
- ACE inhibitors (e.g., lisinopril 10-40mg daily)
- ARBs (e.g., losartan 50-100mg daily)
Treatment Approach
- Treatment should start with a low dose and be titrated upward if blood pressure goals aren't met.
- Combination therapy with two or more medications is recommended for most patients with confirmed hypertension.
- Lifestyle modifications, including reduced sodium intake, regular exercise, weight management, and limited alcohol consumption, should accompany medication therapy for optimal results.
Supporting Evidence
The 2024 ESC guidelines 1 provide the most recent and highest quality evidence for the management of elevated blood pressure and hypertension, and recommend the use of ACE inhibitors, ARBs, dihydropyridine CCBs, and diuretics as first-line treatments. Additionally, the 2023 Diabetes Care guidelines 1 and the 2021 Diabetes Care guidelines 1 also support the use of these medications as first-line treatments for hypertension in patients with diabetes.
From the FDA Drug Label
Losartan is indicated for the treatment of hypertension in adults and pediatric patients 6 years of age and older, to lower blood pressure. Amlodipine besylate tablets is indicated for the treatment of hypertension, to lower blood pressure.
First line anti-hypertensive options include:
- Losartan: an angiotensin II receptor antagonist
- Amlodipine: a calcium channel blocker
Both Losartan 2 and Amlodipine 3 can be used as a first line treatment for hypertension.
From the Research
First-Line Anti-Hypertensive Treatment
The first-line treatment for hypertension includes lifestyle modification and medication.
- Lifestyle modification consists of weight loss, a healthy dietary pattern with low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption 4.
- First-line drug therapy for hypertension includes a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker 4.
Medication Options
Several medication options are available for first-line treatment of hypertension, including:
- Thiazide diuretics, which have been shown to reduce mortality, stroke, coronary heart disease, and cardiovascular events 5, 6.
- Angiotensin-converting enzyme (ACE) inhibitors, which have been shown to reduce mortality, stroke, coronary heart disease, and cardiovascular events 5, 7, 6.
- Calcium channel blockers, which have been shown to reduce stroke and cardiovascular events 5, 6.
- Beta-blockers, which have been shown to reduce stroke and cardiovascular events, but not coronary heart disease or mortality 5, 6.
Comparison of Medication Options
Studies have compared the efficacy of different medication options for first-line treatment of hypertension.
- Low-dose thiazides have been shown to be effective in reducing all morbidity and mortality outcomes 5, 6.
- ACE inhibitors and calcium channel blockers may be similarly effective, but the evidence is less robust 5, 6.
- High-dose thiazides and beta-blockers are inferior to low-dose thiazides 5, 6.
- Angiotensin receptor blockers (ARBs) may have improved tolerability compared to ACE inhibitors, but further study is needed to confirm their efficacy 7.