Prescription for Lisinopril and Hydrochlorothiazide for Hypertension
Direct Prescription Recommendation
For a patient with hypertension and normal labs, prescribe lisinopril 10 mg once daily and hydrochlorothiazide 12.5 mg once daily, both for a 30-day supply. 1, 2
Detailed Prescription Instructions
Lisinopril Prescription
- Medication: Lisinopril 10 mg tablets
- Dosing: Take 1 tablet by mouth once daily
- Quantity: 30 tablets
- Refills: As appropriate for follow-up schedule
- Rationale: The FDA-approved starting dose for hypertension is 10 mg once daily, which can be adjusted based on blood pressure response 2
Hydrochlorothiazide Prescription
- Medication: Hydrochlorothiazide 12.5 mg tablets
- Dosing: Take 1 tablet by mouth once daily
- Quantity: 30 tablets
- Refills: As appropriate for follow-up schedule
- Rationale: When adding a diuretic to lisinopril, the recommended starting dose is 12.5 mg daily 2, 3
Evidence Supporting This Combination
Guideline-Based Rationale
The WHO strongly recommends combination therapy with an ACE inhibitor and thiazide diuretic as first-line treatment for hypertension, preferably as a single-pill combination when available. 1 Since insurance requires separate prescriptions, the individual components at standard starting doses are appropriate.
- The combination of ACE inhibitor plus thiazide diuretic is one of the most effective and well-tolerated two-drug combinations for hypertension 1
- This combination provides complementary mechanisms: renin-angiotensin system blockade and volume reduction 1
- The lisinopril-hydrochlorothiazide combination has been extensively studied and demonstrates superior blood pressure reduction compared to either agent alone 4, 3
Dosing Evidence
The lisinopril 10 mg starting dose is supported by FDA labeling and clinical trials showing effective blood pressure reduction at this dose. 2
- Lisinopril 10 mg produces greater and more rapid blood pressure reduction than 5 mg 2
- The usual dosage range is 20-40 mg daily, allowing for upward titration if needed 2
- When used with diuretics, the recommended starting dose is 5 mg, but for patients not currently on diuretics, 10 mg is appropriate 2
Hydrochlorothiazide 12.5 mg is the evidence-based starting dose when combined with lisinopril. 2, 5, 3
- The lisinopril 20 mg/hydrochlorothiazide 12.5 mg combination demonstrated significantly greater antihypertensive effects than either monotherapy 3
- This dose provides effective blood pressure control while minimizing metabolic side effects 5
- Lisinopril attenuates the hypokalemia induced by thiazide diuretics 6, 5
Monitoring Parameters
Initial Follow-Up Timing
Reassess blood pressure within 2-4 weeks after initiating therapy, with the goal of achieving target blood pressure within 3 months. 1, 7
- Target blood pressure is <140/90 mmHg minimum for patients without comorbidities 1
- Monthly follow-up is suggested after medication initiation until target is reached 1
Laboratory Monitoring
Check serum potassium and creatinine 2-4 weeks after initiating combination therapy. 1, 7
- Monitor for hyperkalemia from ACE inhibitor (though lisinopril helps prevent diuretic-induced hypokalemia) 1
- Monitor for changes in renal function, particularly serum creatinine elevation 1
- Continue monitoring at least annually once stable 1
Common Side Effects to Discuss
Counsel the patient on expected side effects: dizziness (7.5%), headache (5.2%), cough (3.9%), and fatigue (3.7%). 5
- Cough is the most common ACE inhibitor-specific side effect, occurring in approximately 4% of patients 5
- Orthostatic effects occur in 3.2% of patients on combination therapy 5
- Most adverse effects are mild and do not require discontinuation 5
Dose Titration Strategy
If Blood Pressure Remains Uncontrolled
If blood pressure is not controlled after 2-4 weeks, increase lisinopril to 20 mg daily before increasing hydrochlorothiazide. 2, 3
- The usual therapeutic range for lisinopril is 20-40 mg daily 2
- Hydrochlorothiazide can be increased to 25 mg daily if needed 2, 3
- If blood pressure remains uncontrolled on maximum doses of both agents, add a third agent (calcium channel blocker preferred) 1, 7
Critical Pitfall to Avoid
Do not combine lisinopril with an ARB, as dual renin-angiotensin system blockade increases adverse events without additional cardiovascular benefit. 1, 7
Special Considerations for This Patient
Normal Potassium and Creatinine
The patient's normal baseline labs make this combination particularly appropriate, as there is low risk for hyperkalemia or acute kidney injury. 1
- ACE inhibitors can cause hyperkalemia, but this is uncommon with normal baseline renal function 1
- The combination actually helps maintain normal potassium by offsetting diuretic-induced losses 6, 5
Lifestyle Modifications
Reinforce sodium restriction to <2 g/day, which provides additive blood pressure reduction of 5-10 mmHg. 1, 7