What are the common medications for a patient with hypertension?

Common Blood Pressure Medications

The first-line medications for hypertension are thiazide or thiazide-like diuretics (chlorthalidone or hydrochlorothiazide), ACE inhibitors (lisinopril, enalapril), angiotensin receptor blockers (ARBs like losartan, candesartan), and long-acting dihydropyridine calcium channel blockers (amlodipine). 1

Primary Drug Classes for Initial Treatment

Thiazide and Thiazide-Like Diuretics

• Chlorthalidone 12.5-25 mg once daily is the preferred thiazide diuretic based on the strongest evidence from over 50,000 patients in three major trials, demonstrating superior reduction in stroke and heart failure compared to other agents 1, 2, 3
• Hydrochlorothiazide 12.5-50 mg once daily is an acceptable alternative when chlorthalidone is unavailable, though it has a shorter duration of action 1, 4, 2
• Thiazide diuretics reduce cardiovascular mortality by 2-3 deaths per 100 patients treated over 4-5 years 2

ACE Inhibitors

• Lisinopril 10-40 mg once daily is effective across all grades of hypertension and reduces all-cause mortality 1, 5, 2, 6
• Enalapril is another first-line ACE inhibitor option 4
• ACE inhibitors are particularly beneficial for patients with diabetes, chronic kidney disease, heart failure, or coronary artery disease 1, 7

Angiotensin Receptor Blockers (ARBs)

• Losartan 50-100 mg once daily (starting at 25 mg if volume depleted) is effective for hypertension and provides additional benefits in patients with left ventricular hypertrophy 1, 8, 4
• Candesartan 8-32 mg once daily is designed for once-daily administration with proven efficacy 9, 4
• ARBs are preferred over ACE inhibitors when patients cannot tolerate ACE inhibitor-related cough 1

Calcium Channel Blockers

• Amlodipine 5-10 mg once daily is the preferred long-acting dihydropyridine CCB for hypertension 1, 4
• CCBs are particularly effective in Black patients and elderly patients 1, 7
• Amlodipine-related peripheral edema may be attenuated when combined with an ACE inhibitor or ARB 7

Combination Therapy Strategy

Initial Combination Approach

• For most patients with confirmed hypertension, upfront low-dose combination therapy using a single-pill combination of two drug classes is recommended to achieve faster blood pressure control and improve adherence 1
• The preferred combinations are: RAS blocker (ACE inhibitor or ARB) + CCB, RAS blocker + thiazide diuretic, or CCB + thiazide diuretic 1
• Never combine two RAS blockers (ACE inhibitor + ARB) as this increases adverse events without additional benefit 1, 7

Triple Therapy for Uncontrolled Hypertension

• When blood pressure remains uncontrolled on dual therapy, add a third agent to create the combination: RAS blocker + CCB + thiazide diuretic 1, 7
• This triple combination targets complementary mechanisms: volume reduction, vasodilation, and renin-angiotensin system blockade 7

Beta-Blockers: Not First-Line

• Beta-blockers (metoprolol, bisoprolol, carvedilol) are not recommended as first-line agents unless the patient has ischemic heart disease, heart failure with reduced ejection fraction, or requires heart rate control 1
• When needed as fourth-line therapy, vasodilating beta-blockers (labetalol, carvedilol, nebivolol) are preferred 1

Resistant Hypertension (Fourth-Line Agent)

• Spironolactone 25-50 mg daily is the preferred fourth-line agent when blood pressure remains uncontrolled despite optimized triple therapy (RAS blocker + CCB + thiazide diuretic) 1, 7
• Alternative fourth-line agents if spironolactone is not tolerated include eplerenone 50-200 mg daily, amiloride, or a beta-blocker 1

Blood Pressure Targets

• Target blood pressure is <140/90 mmHg for most patients 1, 7
• For patients with known cardiovascular disease or 10-year ASCVD risk ≥10%, target <130/80 mmHg 1
• For high-risk patients (diabetes, chronic kidney disease, high CVD risk), a systolic target <130 mmHg may be reasonable 1

Race-Specific Considerations

• For Black patients, initial therapy should be a CCB or thiazide diuretic rather than an ACE inhibitor or ARB alone, as these are more effective in this population 1, 7
• The combination of CCB + thiazide diuretic may be more effective than CCB + ARB in Black patients 1, 7

Critical Monitoring Parameters

• Reassess blood pressure within 2-4 weeks after initiating or adjusting therapy, with the goal of achieving target within 3 months 1, 7
• Monitor serum potassium and creatinine 2-4 weeks after starting ACE inhibitors, ARBs, or diuretics to detect hyperkalemia, hypokalemia, or acute kidney injury 1, 7
• Confirm adherence before escalating therapy, as non-adherence is the most common cause of apparent treatment resistance 7