What initial dose of an angiotensin‑converting enzyme inhibitor (e.g., lisinopril) or angiotensin II receptor blocker should be started in a physically active patient with stage 2 hypertension who wants to avoid diuretics because of concerns about sexual dysfunction?

Initial ACE Inhibitor Dosing for Stage 2 Hypertension in a Physically Active Patient

Start lisinopril 10 mg once daily, not 150 mg (which is not a valid dose), and avoid diuretics initially given the patient's sexual function concerns and high exercise volume. 1

Rationale for Lisinopril 10 mg Starting Dose

• The FDA-approved initial dose for hypertension is 10 mg once daily in adults, with titration based on blood pressure response to a usual range of 20–40 mg daily. 1
• Starting at 10 mg provides effective blood pressure reduction (11–15% systolic, 13–17% diastolic) while minimizing the risk of first-dose hypotension, which is particularly important in this physically active patient who exercises intensely six days per week. 2
• Lisinopril reaches peak serum concentrations 6–8 hours after dosing and provides smooth, gradual blood pressure reduction over 24 hours without affecting heart rate or cardiovascular reflexes—ideal for someone maintaining a rigorous training schedule. 2

Why Not Start with a Diuretic

• The patient explicitly expressed concern about sexual dysfunction from diuretics, which is a well-documented adverse effect that significantly impacts quality of life and medication adherence. 3
• For non-Black patients with stage 2 hypertension, ACE inhibitors are equally appropriate first-line agents as thiazide diuretics, and the 2017 ACC/AHA guidelines support starting with either class. 3
• Diuretics can cause volume depletion during intense exercise, potentially leading to dehydration, electrolyte disturbances, and impaired athletic performance in someone working out 30–60 minutes daily six days per week. 3

Expected Titration Path

• If blood pressure remains ≥140/90 mmHg after 2–4 weeks on lisinopril 10 mg, increase to 20 mg once daily before adding a second agent. 1
• The usual therapeutic range is 20–40 mg daily; doses up to 80 mg have been studied but provide minimal additional benefit beyond 40 mg. 1
• If lisinopril monotherapy at 20–40 mg fails to achieve target blood pressure (<130/80 mmHg for most patients), add a calcium channel blocker (amlodipine 5–10 mg) rather than a diuretic as the second agent, given the patient's concerns. 4, 5

Monitoring and Follow-Up

• Recheck blood pressure within 2–4 weeks of starting lisinopril to assess response, as steady-state is achieved in 2–3 days with peak antihypertensive effect around 6 hours and sustained effect for 24 hours. 2
• Check serum potassium and creatinine at baseline and 2–4 weeks after initiation to detect hyperkalemia or acute kidney injury, which are class-related adverse effects of ACE inhibitors. 3, 5
• Target blood pressure is <130/80 mmHg for most adults; at minimum <140/90 mmHg. 3, 5

When to Add a Second Agent

• If blood pressure remains uncontrolled on lisinopril 20–40 mg after 4 weeks, add amlodipine 5–10 mg once daily to create the guideline-recommended ACE inhibitor + calcium channel blocker combination. 4, 5
• This combination provides complementary mechanisms (renin-angiotensin system blockade plus vasodilation) and has demonstrated superior blood pressure control compared to either agent alone. 4
• Amlodipine does not cause sexual dysfunction and is weight-neutral, making it ideal for this patient's concerns and activity level. 4

Only Add a Diuretic as Third-Line

• If blood pressure remains ≥140/90 mmHg on lisinopril + amlodipine at optimal doses, then add hydrochlorothiazide 12.5–25 mg or chlorthalidone 12.5–25 mg once daily to achieve triple therapy. 4, 5
• At that point, the benefits of blood pressure control outweigh the sexual dysfunction concern, and you can counsel the patient that the risk is lower with low-dose thiazides in combination therapy. 3
• Chlorthalidone is preferred over hydrochlorothiazide due to longer duration of action and superior cardiovascular outcomes data. 4, 5

Critical Pitfalls to Avoid

• Do not start with 150 mg of any ACE inhibitor or ARB—this is not a valid dose and would cause severe hypotension, especially in a volume-depleted athlete. 1
• Do not force a diuretic on a patient who has explicitly expressed concerns about sexual dysfunction; this will destroy adherence and therapeutic alliance. 3
• Do not assume that because the patient has stage 2 hypertension, you must start with combination therapy—monotherapy with appropriate titration is acceptable when patient concerns warrant a stepwise approach. 3, 1
• Do not forget to counsel the patient to hold ACE inhibitors if experiencing volume depletion from illness, as this increases the risk of acute kidney injury. 3

Lifestyle Reinforcement

• Reinforce sodium restriction to <2 g/day, which provides an additional 5–10 mmHg systolic reduction and enhances ACE inhibitor efficacy. 5
• The patient's current exercise regimen (aerobic 30 min/day six days/week plus resistance training four days/week) already provides optimal blood pressure benefit and should be continued. 5
• Ensure adequate hydration given the high exercise volume, as dehydration can interfere with blood pressure control and increase the risk of ACE inhibitor-related acute kidney injury. 3