What is the recommended initial treatment approach for a patient with hypertension, particularly those with a history of diabetes or kidney disease?

Management of High Blood Pressure

Initial Treatment Approach

For patients with hypertension, particularly those with diabetes or kidney disease, treatment should begin immediately with both lifestyle modifications and pharmacologic therapy tailored to blood pressure severity and comorbid conditions. 1

Blood Pressure Thresholds for Pharmacologic Treatment

Patients with diabetes and BP ≥130/80 mmHg require pharmacologic intervention:

• BP 130-149/80-89 mmHg: Initiate single-drug therapy alongside lifestyle changes 1, 2
• BP ≥150/90 mmHg: Start with two antihypertensive medications immediately (or single-pill combination) to achieve control more effectively 1

First-Line Medication Selection

For patients with diabetes and albuminuria (UACR ≥30 mg/g):

• ACE inhibitor or ARB is mandatory as first-line therapy to reduce progressive kidney disease risk 1
• Start with lisinopril 10 mg daily or losartan 50 mg daily 2, 3
• If ACE inhibitor not tolerated, substitute with ARB 1

For patients with diabetes WITHOUT albuminuria:

• Any of four drug classes proven to reduce cardiovascular events: ACE inhibitors, ARBs, thiazide-like diuretics (chlorthalidone or indapamide preferred), or dihydropyridine calcium channel blockers 1
• For Black patients specifically, thiazide-like diuretic or dihydropyridine CCB is preferred initial therapy 2

For patients with diabetes AND established coronary artery disease:

• ACE inhibitors or ARBs are recommended as first-line therapy regardless of albuminuria status 1

Comorbidity-Specific Medication Selection

The following table guides medication choice based on specific comorbidities 1:

• Chronic kidney disease: ACE inhibitor or ARB (ARB if ACE inhibitor not tolerated)
• Heart failure with reduced ejection fraction: Guideline-directed beta blockers; avoid non-dihydropyridine calcium antagonists
• Heart failure with preserved ejection fraction: Diuretics for volume overload; add ACE inhibitor/ARB and beta blocker for BP control
• Post-MI or stable ischemic heart disease: Guideline-directed beta blockers plus ACE inhibitor or ARB
• Atrial fibrillation: ARBs may reduce recurrence

Lifestyle Modifications (Mandatory for All Patients)

Dietary interventions 1:

• Sodium restriction to <2,300 mg/day (ideally <2,000 mg/day or reduce by ≥1,000 mg/day)
• Increase dietary potassium to 3,500-5,000 mg/day
• DASH diet pattern: 8-10 servings fruits/vegetables daily, 2-3 servings low-fat dairy, whole grains, reduced saturated fat

Physical activity 1:

• Minimum 150 minutes/week moderate-intensity aerobic exercise
• Alternative: 90-150 minutes/week dynamic resistance training or 3 sessions/week isometric resistance

Weight management 1:

• Target weight loss of at least 1 kg if overweight/obese through caloric restriction

Alcohol moderation 1:

• ≤2 drinks/day for men, ≤1 drink/day for women

Medication Titration Strategy

Follow-up schedule 1:

• Reassess approximately monthly until BP controlled
• Monitor within 2-4 weeks after medication initiation or dose changes

If BP remains uncontrolled on monotherapy 2, 4:

1. First, optimize initial medication to maximum recommended dose
2. Then add second agent from different class:
   • If started on ACE inhibitor/ARB: add dihydropyridine CCB (amlodipine 5-10 mg) or thiazide-like diuretic
   • Prefer CCB over thiazide to reduce diabetes risk 4

Multiple-drug therapy considerations 1:

• Most patients require multiple medications to achieve target BP
• Never combine ACE inhibitor + ARB (increased hyperkalemia, syncope, acute kidney injury without added cardiovascular benefit) 1
• Never combine ACE inhibitor or ARB with direct renin inhibitor 1

Blood Pressure Targets

Target BP <130/80 mmHg for most adults with diabetes 1, 5

Critical Monitoring Requirements

Laboratory monitoring when using ACE inhibitors, ARBs, or diuretics 1:

• Check serum creatinine/eGFR and potassium at baseline
• Recheck 7-14 days after initiation or dose change
• Monitor at least annually thereafter
• Watch for hyperkalemia with ACE inhibitors/ARBs

Continuation of ACE inhibitor/ARB in advanced kidney disease:

• May continue even as eGFR declines to <30 mL/min/1.73 m² for cardiovascular benefit without significantly increasing end-stage kidney disease risk 1

Important Contraindications

ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors:

• Avoid in sexually active individuals of childbearing potential not using reliable contraception
• Absolutely contraindicated in pregnancy 1

When to Refer to Specialist

Refer to hypertension specialist if 4, 5:

• BP remains uncontrolled on 3 or more medications (resistant hypertension)
• Suspected secondary causes of hypertension
• Severe or rapidly progressive hypertension

Common Pitfalls to Avoid

• Do not delay pharmacologic therapy in patients with diabetes—lifestyle changes alone are insufficient at BP ≥130/80 mmHg 1
• Do not use ACE inhibitor + ARB combination—this increases adverse events without benefit 1
• Do not forget albuminuria screening—this determines whether ACE inhibitor/ARB is mandatory vs. optional 1
• Do not use non-dihydropyridine CCBs (diltiazem, verapamil) in heart failure with reduced ejection fraction 1
• Do not start with monotherapy if BP ≥150/90 mmHg—two drugs are needed from the outset 1