What blood pressure medications do not cause weight gain as a side effect in a patient with hypertension?

Blood Pressure Medications Without Weight Gain

For patients with hypertension concerned about weight gain, prioritize ACE inhibitors, ARBs, or calcium channel blockers as first-line therapy, while avoiding beta-blockers (except vasodilating types if required) and thiazide diuretics. 1

Weight-Neutral First-Line Options

ACE Inhibitors and ARBs (Preferred)

• ACE inhibitors (such as enalapril) and ARBs (such as candesartan or telmisartan) are weight-neutral and particularly desirable for patients with obesity or weight concerns because angiotensin is overexpressed in obesity 1, 2
• These agents are recommended as first-line therapy for hypertension and have demonstrated cardiovascular protection and reduction in CVD events by 20-30% with a 10 mm Hg systolic BP reduction 3, 2
• ARBs offer superior tolerability compared to ACE inhibitors, with lower rates of side effects like cough 4, 5
• For patients at increased cardiovascular risk, telmisartan has demonstrated equivalent protection to ACE inhibitors with a better side-effect profile 4

Calcium Channel Blockers (Alternative Weight-Neutral Option)

• Calcium channel blockers (such as amlodipine) are weight-neutral and appropriate as first-line therapy 1, 2
• Dihydropyridine calcium channel blockers are recommended in combination with ACE inhibitors or ARBs when multiple-drug therapy is needed to achieve blood pressure targets 3
• These agents are particularly useful when added to ACE inhibitors or beta-blockers, as demonstrated in major trials 3

Medications to AVOID for Weight-Concerned Patients

Beta-Blockers (Avoid as First-Line)

• Beta-blockers as a class should be avoided as first-line antihypertensive treatment in patients with overweight or obesity due to adverse metabolic effects including weight gain, negative effects on lipids, and insulin resistance 1
• Traditional beta-blockers showed more weight gain and withdrawals due to side effects in clinical trials 3
• If a beta-blocker is medically required (for coronary artery disease, heart failure, or arrhythmias), prioritize vasodilating beta-blockers like carvedilol or nebivolol over bisoprolol or metoprolol 1

Thiazide Diuretics (Use with Caution)

• Thiazide diuretics should be avoided in weight-concerned patients due to dose-related side effects including dyslipidemia and insulin resistance 1
• While thiazide-like diuretics (chlorthalidone, hydrochlorothiazide) are recommended as first-line therapy for general hypertension management, their metabolic effects make them less ideal when weight is a primary concern 3, 2

Treatment Algorithm for Weight-Concerned Patients

Initial Monotherapy

• Start with an ACE inhibitor or ARB as first-line therapy 3, 1, 2
• Alternative: Use a calcium channel blocker if ACE inhibitor/ARB is contraindicated 1, 2

If Blood Pressure Not Controlled (140/90 to 159/99 mm Hg)

• Add a calcium channel blocker to the ACE inhibitor/ARB 3
• Avoid adding beta-blockers or thiazide diuretics if weight is a concern 1

If Blood Pressure ≥160/100 mm Hg

• Initiate two-drug therapy or single-pill combination with ACE inhibitor/ARB plus calcium channel blocker 3
• Multiple-drug therapy is generally required to achieve blood pressure targets (<130/80 mm Hg for adults <65 years) 3, 2

Resistant Hypertension (Not Meeting Target on Three Drugs)

• Consider mineralocorticoid receptor antagonist therapy if not meeting targets on three classes including a diuretic 3
• Refer to specialist with expertise in blood pressure management 3

Important Clinical Caveats

• Never combine ACE inhibitors with ARBs or with direct renin inhibitors due to lack of added cardiovascular benefit and increased adverse events (hyperkalemia, syncope, acute kidney injury) 3
• Lifestyle modifications including weight loss, sodium restriction (<2,300 mg/day), and physical activity should be initiated alongside pharmacologic therapy 3, 2
• Only 44% of US adults with hypertension achieve adequate blood pressure control, emphasizing the need for appropriate medication selection and titration 2