When should I start medication?

When to Start Medication for Hypertension

Start antihypertensive medication immediately if your blood pressure is ≥140/90 mmHg confirmed by home monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg), using a two-drug combination from the outset rather than sequential monotherapy. 1, 2

Blood Pressure Thresholds for Immediate Pharmacologic Treatment

Stage 2 Hypertension (≥140/90 mmHg)

• Begin dual-drug combination therapy immediately upon diagnosis confirmation—do not delay with lifestyle modifications alone 3, 1, 2
• Initiate with a single-pill combination containing two agents from different classes: ACE inhibitor or ARB + calcium channel blocker OR ACE inhibitor or ARB + thiazide-like diuretic 1, 2
• For Black patients specifically, the preferred initial regimen is calcium channel blocker + thiazide-like diuretic, as this population responds less effectively to ACE inhibitors as monotherapy 1, 2

Stage 1 Hypertension (130-139/80-89 mmHg)

• Start medication immediately if you have established cardiovascular disease (prior MI, stroke, heart failure, coronary disease) 1, 2
• Start medication immediately if your 10-year ASCVD risk is ≥10% 1
• Start medication immediately if you have diabetes mellitus or chronic kidney disease 1, 2
• For low-risk patients (young, no comorbidities, pre-menopausal women), you may defer medication and attempt lifestyle modifications for 3-6 months before starting pharmacotherapy 3

High-Normal Blood Pressure (130-139/80-89 mmHg)

• Taiwan guidelines uniquely recommend starting medication even at this threshold if additional cardiovascular risk factors are present 3
• Most other guidelines (ESH/ESC, NICE, Canadian) recommend lifestyle modifications first for 3-12 months unless high-risk features exist 3

Confirmation Before Starting Treatment

Verify true hypertension before initiating lifelong therapy:

• Confirm office readings ≥140/90 mmHg with home blood pressure monitoring showing average ≥135/85 mmHg 1, 2
• Alternatively, use 24-hour ambulatory monitoring showing average ≥130/80 mmHg 1, 2
• NICE guidelines uniquely recommend using ABPM or HBPM to confirm all new diagnoses before starting medication 3
• However, do not delay treatment while awaiting confirmation if blood pressure is severely elevated (≥160/100 mmHg) 2

Initial Medication Regimen

First-Line Dual Therapy

• For non-Black patients: ACE inhibitor or ARB + calcium channel blocker (preferred) OR ACE inhibitor or ARB + thiazide-like diuretic 1, 2
• For Black patients: Calcium channel blocker + thiazide-like diuretic (most effective) OR calcium channel blocker + ACE inhibitor/ARB 1, 2
• Use single-pill fixed-dose combinations whenever possible to improve adherence 1, 2

Specific Drug Choices

• ACE inhibitor: Lisinopril 10 mg daily (titrate to 20-40 mg) 4
• ARB: Losartan 50 mg daily (titrate to 100 mg) or valsartan 160 mg daily 4
• Calcium channel blocker: Amlodipine 5 mg daily (titrate to 10 mg) 4, 1
• Thiazide-like diuretic: Chlorthalidone 12.5-25 mg daily (preferred over hydrochlorothiazide due to superior 24-hour control and cardiovascular outcomes) 4, 1

Blood Pressure Targets

• Primary target: <130/80 mmHg for most adults 1, 2
• Minimum acceptable target: <140/90 mmHg 3, 1
• Optimal target: 120-129 mmHg systolic if well tolerated 4, 2
• For patients ≥80 years: <150/90 mmHg is acceptable, though <140/90 mmHg is preferred if tolerated 3
• For patients ≥60 years (JNC 8): <150/90 mmHg 3

Timeline for Achieving Control

• Reassess blood pressure within 2-4 weeks after starting medication 4, 1, 2
• Achieve target blood pressure within 3 months of initiating or modifying therapy 4, 1, 2
• Schedule monthly follow-up during dose titration until target is reached 1
• Once controlled, follow up every 3-6 months 1

When to Escalate to Triple Therapy

• If blood pressure remains ≥140/90 mmHg after 4-8 weeks on optimized dual therapy, add a third agent from the remaining class 4, 1
• Standard triple therapy: ACE inhibitor or ARB + calcium channel blocker + thiazide-like diuretic 4, 1
• Optimize doses of the first two drugs before adding the third agent 2

Monitoring After Starting Medication

• Check serum potassium and creatinine 7-14 days after starting ACE inhibitor, ARB, or diuretic 1, 2
• Monitor for side effects: cough with ACE inhibitors, peripheral edema with calcium channel blockers, hypokalemia with thiazides 4
• Encourage home blood pressure monitoring throughout treatment 1

Critical Pitfalls to Avoid

• Never start with monotherapy and sequential titration—combination therapy from the outset is more effective and reaches target faster 1, 2
• Never combine an ACE inhibitor with an ARB (dual RAS blockade)—this increases hyperkalemia and acute kidney injury risk without cardiovascular benefit 4, 1, 2
• Never use beta-blockers as first-line therapy unless compelling indications exist (angina, post-MI, heart failure, atrial fibrillation) 1, 2
• Never delay treatment intensification when blood pressure remains above target—adjust therapy within 2-4 weeks 4, 1
• Never assume treatment failure without first confirming medication adherence, as non-adherence is the most common cause of apparent resistance 4, 1, 2

Lifestyle Modifications (Start Simultaneously, Not Sequentially)

• Sodium restriction to <2 g/day provides 5-10 mmHg systolic reduction 4, 1
• DASH dietary pattern reduces blood pressure by 11.4/5.5 mmHg 4, 1
• Weight loss of 10 kg reduces blood pressure by 6/4.6 mmHg 4, 1
• Aerobic exercise ≥150 minutes/week reduces blood pressure by 4/3 mmHg 4, 1
• Limit alcohol to ≤2 drinks/day for men, ≤1 drink/day for women 4, 1
• These modifications are adjunctive to medication, not alternatives—start both together 1, 2