All patients should pursue lifestyle modifications. See below for recommendations on the initial drug of choice for hypertensive adults, from the JNC 8:
| Population | Strength of Recommendation | Initial Drug Therapy Options |
|---|---|---|
| Non-black population, including those with diabetes | B (moderate) | thiazide-type diuretic calcium channel blocker (CCB) angiotensin-converting enzyme inhibitor (ACEI) angiotensin receptor blocker (ARB) |
| General black population, including those with diabetes | For general black population: B (moderate)For black patients with diabetes: C (weak) |
thiazide-type diuretic CCB |
| CKD (all races, with or without DM) |
B (moderate) | ACEI ARB (initial or added to existing regimen, to improve kidney outcomes) |
| Patients presenting w/SBP >160 or DBP >100 | “Some committee members” | Use any 2 medications (from different classes) simultaneously |
Initial Drug Therapies
- have been found have the best reduction in morbidity and mortality in regards to hypertension
- have known benefits and side effect profiles with >70 years of data
- are extremely inexpensive drugs (estimated cost is $5 for a 30 day supply)
If the thiazide diuretic does not optimize the blood pressure, you should continue the thiazide but add another agent from the following classes of antihypertensives: ACE inhibitor, ARBs, or calcium channel blockers. They have all been found to work synergistically with the thiazide diuretic to reduce blood pressure and all have data demonstrating equivalent reduction of morbidity and mortality.
*In JNC 8, ACEI or ARB therapy is recommended initially for patients with chronic kidney disease.
In contrast to fairly common practice prior to JNC 8, beta-blockers are not recommended for initial drug therapy in any hypertensive patient (although beta-blockers may be used as add-on therapy, as addressed later in the module).
Stage 2 Hypertension
Stage 2 hypertensive patients are rarely controlled on one class of medication alone. According to the evidence, most will require a two-drug combination (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Combination pills (example: losartan –hydrochlorothiazide; lisinopril – hydrochlorothiazide, etc.) can reduce the pill burden for patients.
Special caution must be exercised in initial combined therapy in those at risk for orthostatic hypotension such as the elderly, diabetic patients, and patients with autonomic dysfunctions (ex. paraplegic patients).
Some providers are reluctant to start combination medications in newly diagnosed hypertensive patients. If there is a negative side effect, there may be difficulty in pinpointing which is the offending agent in a combination medication.
| Evidence-based initial and target dosing for select anti-hypertensive drugs | ||||
|---|---|---|---|---|
| Class | Example Medication | Initial Daily Dose, mg | Target Dose from RCTs Reviewed in JNC 8 | Number of Doses / Day |
| ACEI | lisinopril | 10 | 40 | 1 |
| ARB | losartan | 50 | 100 | 1-2 |
| BB | metoprolol | 50 | 100-200 | 1-2 |
| CCB | amlodipine | 2.5 | 10 | 1 |
| diltiazem ER | 120-180 | 360 | 1 | |
| Thiazides | chlorthalidone | 12.5 | 12.5-25 | 1 |
| HCTZ | 12.5-25 | 25-100* | 1-2 | |
*Current evidence-based recommended dose is 25 mg to balance safety and efficacy
| << Lifestyle Modifications |