What is the initial medication and dosage for an adult patient with newly diagnosed hypertension, considering factors such as blood pressure reading, race (including African descent), and comorbidities like diabetes or impaired renal function?

Blood Pressure Medication Initiation Flowsheet

Step 1: Confirm Diagnosis & Determine Treatment Threshold

Start pharmacological treatment when:

• SBP ≥140 mmHg OR DBP ≥90 mmHg with confirmed hypertension 1
• SBP 130-139 mmHg with existing cardiovascular disease 1
• SBP 130-139 mmHg with diabetes, chronic kidney disease, or high cardiovascular risk (10-year risk ≥10%) 1

Confirm diagnosis with out-of-office measurements (home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg) before initiating treatment 1

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Step 2: Initial Medication Selection

For Black Patients:

Start with a calcium channel blocker (CCB) OR thiazide diuretic 1, 2

• Amlodipine 5 mg once daily (preferred CCB) 2, 3
• OR Chlorthalidone 12.5-25 mg once daily (preferred thiazide-like diuretic) 2
• OR Hydrochlorothiazide 12.5-25 mg once daily (alternative thiazide) 1, 3

For stage 2 hypertension (≥160/100 mmHg) in Black patients, start combination therapy immediately:

• Amlodipine 5 mg + Chlorthalidone 12.5 mg once daily 1, 2

For Non-Black Patients:

Start with ACE inhibitor, ARB, CCB, OR thiazide diuretic 1

Preferred initial agents:

• Lisinopril 10 mg once daily (ACE inhibitor) 3
• Losartan 50 mg once daily (ARB) 1
• Amlodipine 5 mg once daily (CCB) 2, 3
• Chlorthalidone 12.5-25 mg once daily (thiazide-like diuretic) 2

For stage 2 hypertension (≥160/100 mmHg) in non-Black patients, start combination therapy immediately:

• Lisinopril 10 mg + Amlodipine 5 mg once daily 1
• OR Losartan 50 mg + Amlodipine 5 mg once daily 1

Special Populations:

Diabetes mellitus:

• Prefer ACE inhibitor or ARB as first-line 4
• Lisinopril 10 mg once daily OR Losartan 50 mg once daily 3, 4
• Target BP <130/80 mmHg 1, 4

Chronic kidney disease (eGFR 30-59 mL/min/1.73m²):

• Prefer ACE inhibitor or ARB as first-line 1
• Lisinopril 5-10 mg once daily (start lower dose if eGFR <45) 3
• Target BP <130/80 mmHg 1

Heart failure:

• Lisinopril 5 mg once daily (start 2.5 mg if serum sodium <130 mEq/L) 3
• Avoid non-dihydropyridine CCBs (diltiazem, verapamil) 2

Existing cardiovascular disease:

• Target BP <130/80 mmHg 1
• Prefer ACE inhibitor or ARB 1

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Step 3: Follow-Up & Dose Titration Schedule

Reassess BP monthly after initiation or medication change until target achieved 1

If BP Not at Target After 2-4 Weeks:

Option A: Uptitrate current medication

• Lisinopril: increase to 20 mg, then 40 mg (max 80 mg) 3
• Amlodipine: increase to 10 mg 2, 3
• Chlorthalidone: increase to 25 mg 2
• Losartan: increase to 100 mg 2

Option B: Add second agent from different class (preferred if BP >20/10 mmHg above target) 1

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Step 4: Adding Second Agent (Dual Therapy)

If Starting on ACE Inhibitor/ARB:

Add CCB OR thiazide diuretic 1

• Amlodipine 5 mg once daily 2
• OR Chlorthalidone 12.5-25 mg once daily 2

If Starting on CCB:

Add ACE inhibitor/ARB OR thiazide diuretic 1, 2

• Lisinopril 10 mg once daily 3
• OR Chlorthalidone 12.5-25 mg once daily 2
• For Black patients, prefer adding thiazide over ACE inhibitor/ARB 1, 2

If Starting on Thiazide:

Add ACE inhibitor/ARB OR CCB 1

• Lisinopril 10 mg once daily 3
• OR Amlodipine 5 mg once daily 2

Strongly prefer single-pill combinations to improve adherence 1

Reassess BP in 2-4 weeks, uptitrate doses monthly until target achieved 1

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Step 5: Adding Third Agent (Triple Therapy)

If BP remains uncontrolled on dual therapy at optimal doses, add third agent from remaining class 1

Standard triple therapy combination: ACE inhibitor/ARB + CCB + Thiazide diuretic 1, 2

Example regimens:

• Lisinopril 20-40 mg + Amlodipine 10 mg + Chlorthalidone 12.5-25 mg once daily 2, 3
• Losartan 100 mg + Amlodipine 10 mg + Chlorthalidone 12.5-25 mg once daily 2

Monitor serum potassium and creatinine 2-4 weeks after adding diuretic 2

Reassess BP in 2-4 weeks 1

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Step 6: Resistant Hypertension (Fourth Agent)

If BP remains ≥140/90 mmHg on triple therapy at optimal doses:

Before adding fourth agent:

• Verify medication adherence (most common cause of treatment failure) 1, 2
• Screen for secondary hypertension (primary aldosteronism, renal artery stenosis, sleep apnea) 1
• Review for interfering medications (NSAIDs, steroids, oral contraceptives) 1
• Reinforce sodium restriction <2 g/day 2

Add spironolactone as preferred fourth-line agent:

• Spironolactone 25-50 mg once daily 2
• Monitor potassium closely (risk of hyperkalemia with ACE inhibitor/ARB) 2

Alternative fourth-line agents if spironolactone contraindicated:

• Doxazosin 1-8 mg once daily 2
• Beta-blocker (if compelling indication: angina, post-MI, heart failure) 1

Consider referral to hypertension specialist if BP remains uncontrolled on four-drug therapy 2

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Blood Pressure Targets

Standard target: <140/90 mmHg for all patients 1

Intensive targets (<130/80 mmHg) for:

• Existing cardiovascular disease 1
• Diabetes mellitus 1, 4
• Chronic kidney disease 1
• High cardiovascular risk (10-year risk ≥10%) 1

Avoid diastolic BP <70 mmHg (increased risk of ischemic events) 1, 5

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Monitoring Schedule

Monthly follow-up after initiation or medication change until target achieved 1

Every 3-5 months once BP controlled 1

Check serum potassium and creatinine:

• Baseline before starting ACE inhibitor/ARB or diuretic 1, 2
• 2-4 weeks after starting or dose change 2
• Annually if stable 1

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Critical Pitfalls to Avoid

Never combine ACE inhibitor + ARB (increases adverse events without benefit) 1, 2

Never use non-dihydropyridine CCBs (diltiazem, verapamil) in heart failure 2

Never delay treatment intensification—most patients require 2-3 medications to achieve target 1, 4, 6

Never stage hypertension on single BP reading—confirm with multiple measurements 7

Never add third drug class before optimizing doses of current two-drug regimen 2

Never assume treatment failure without confirming adherence first 2, 7