What are the common antihypertensive medications?

Common Blood Pressure Medications

The five major classes of antihypertensive medications suitable for initiating and maintaining treatment are: thiazide diuretics, calcium channel blockers, ACE inhibitors, angiotensin receptor blockers (ARBs), and beta-blockers. 1

First-Line Medication Classes

Thiazide and Thiazide-Like Diuretics

• Hydrochlorothiazide is the most commonly prescribed thiazide diuretic 2
• Chlorthalidone provides superior 24-hour blood pressure reduction compared to hydrochlorothiazide and should be preferentially used, particularly in resistant hypertension 1
• Indapamide is another thiazide-like diuretic effective for blood pressure control 1
• These agents have been the basis of antihypertensive therapy in the majority of placebo-controlled outcome trials demonstrating reduction in cardiovascular events 1

ACE Inhibitors

• Enalapril is a commonly used ACE inhibitor 2
• Lisinopril is frequently prescribed in combination therapy 3
• Ramipril has demonstrated cardiovascular event reduction in high-risk patients 4
• ACE inhibitors are contraindicated in pregnancy, bilateral renal artery stenosis, and history of angioedema 3

Angiotensin Receptor Blockers (ARBs)

• Candesartan is a first-line ARB option 2
• Valsartan is commonly used in combination therapy 5
• Losartan demonstrated superior stroke reduction compared to beta-blockers in the LIFE study 1
• ARBs should never be combined with ACE inhibitors due to lack of benefit and increased adverse events 3, 5

Calcium Channel Blockers

• Amlodipine is the most commonly prescribed dihydropyridine calcium channel blocker 2
• Nicardipine is particularly effective in hypertensive emergencies and may be superior to labetalol for achieving short-term blood pressure targets 1
• Clevidipine is used for acute blood pressure management in specific conditions 1

Beta-Blockers

• Atenolol is indicated for hypertension, angina, and post-myocardial infarction management 6
• Metoprolol is effective for hypertension, angina, and myocardial infarction 7
• Labetalol is preferred in hypertensive emergencies, particularly with acute aortic dissection 1
• Esmolol is a short-acting beta-blocker used in acute settings 1
• Beta-blockers should not be used in patients with metabolic syndrome or high diabetes risk, especially when combined with thiazide diuretics, due to dysmetabolic effects 1

Combination Therapy Approach

More than 70% of adults treated for hypertension will require at least two antihypertensive agents to achieve adequate blood pressure control. 8

Preferred Two-Drug Combinations

• ACE inhibitor or ARB + dihydropyridine calcium channel blocker (e.g., lisinopril + amlodipine or valsartan + amlodipine) is the optimal initial combination for confirmed hypertension ≥140/90 mmHg 3, 5
• Thiazide diuretic + any other class consistently demonstrates superior efficacy compared to combinations without a diuretic 1

Three-Drug Combination

• RAS blocker (ACE inhibitor or ARB) + calcium channel blocker + thiazide/thiazide-like diuretic is the recommended triple therapy when two drugs fail to achieve target blood pressure 3, 5

Additional Agents for Resistant Hypertension

Aldosterone Antagonists

• Spironolactone and other mineralocorticoid receptor antagonists provide add-on benefit in patients uncontrolled on multidrug regimens 1

Loop Diuretics

• Furosemide requires at least twice-daily dosing due to short duration of action 1
• Torsemide has longer duration and can be dosed once daily 1
• Loop diuretics are necessary in patients with chronic kidney disease (creatinine clearance <30 mL/min) for effective volume control 1

Centrally Acting Agents

• These are effective but have higher incidence of adverse effects and lack outcome data 1

Direct Vasodilators

• Hydralazine is used in resistant hypertension and is preferred in eclampsia/preeclampsia 1
• Minoxidil is very effective at higher doses but requires concomitant beta-blocker and loop diuretic due to reflex tachycardia and fluid retention 1

Critical Prescribing Considerations

The main benefits of antihypertensive therapy are due to blood pressure lowering per se, largely independent of the specific drugs employed. 1 However, specific comorbidities and patient characteristics should guide drug selection 1.