FAQs on First-Line BP Meds

Introduction

As a clinical pharmacist, you often encounter questions about choosing blood pressure medications for the initial treatment of uncomplicated hypertension. We know to turn to an ACEI or ARB, calcium channel blocker (CCB), or thiazide first, CV benefits seem similar overall. But be ready with answers to common questions about nuances...

Table (1). Oral Drugs Commonly Used in Treatment of Hypertension
Drug Class	Examples	Total Daily Dose (DOSING frequency/day)	Adverse Effects
Diuretics
Thiazides	Hydrochlorothiazide	6.25–50 mg (1–2)	Hypokalemia, hyperuricemia, gout, hyperglycemia, ↑ cholesterol, ↑ triglycerides
Thiazide-like	Chlorthalidone	25–50 mg (1)	same as above
Loop diuretics	Furosemide	40–80 mg (2–3)	Hypokalemia, hyperuricemia
	Ethacrynic acid	50–100 mg (2-3)
Aldosterone antagonists	Spironolactone	25–100 mg (1–2)	Hyperkalemia, gynecomastia
	Eplerenone	50–100 mg (1–2)	Hyperkalemia
K+-retaining	Amiloride	5–10 mg (1–2)
	Triamterene	50–100 mg (1–2)
Beta blockers
β1-selective	Atenolol	25–100 mg (1–2)	Bronchospasm, bradycardia, heart block, fatigue, sexual dysfunction
	Metoprolol	25–100 mg (1–2)	same as above
Nonselective	Propranolol	40–160 mg (2)	same as above
	Propranolol LA	60–180 mg (1)	same as above
Combined alpha/beta	Labetolol	200–800 mg (2)	Bronchospasm, bradycardia, heart block
	Carvedilol	12.5–50 mg (2)
ACE inhibitors	Captopril	25–200 mg (2)	Cough, hyperkalemia, azotemia, angioedema
	Lisinopril	10–40 mg (1)
	Ramipril	2.5–20 mg (1–2)
Angiotensin II receptor blockers	Losartan	25–100 mg (1–2)	Hyperkalemia, azotemia
	Valsartan	80–320 mg (1)
	Candesartan	2–32 mg (1–2)
Calcium channel antagonists
Dihydropyridines	Nifedipine long-acting	30–60 mg (1)	Edema, constipation
Nondihydropyridines	Verapamil long-acting	120–360 mg (1–2)	Constipation, bradycardia, heart block
	Diltiazem long-acting	180–420 mg (1)

NPS-adv

Questions

Is an ACEI preferred over an ARB?

Not necessarily. Overall data suggest that ARBs reduce CV risk on par with ACEIs. But ARBs cause fewer adverse effects, such as cough or angioedema, than ACEIs. And both have low-cost generics. Choose an ARB over an ACEI if starting one of these.

• Lean toward a long-acting ARB, such as telmisartan or olmesartan. This may reduce BP swings or help with adherence.
• Keep in mind, losartan is the shortest-acting ARB and often needs to be dosed BID.
• But don’t switch from an ACEI to an ARB for a patient who’s on an optimized regimen with an ACEI and is tolerating it well.

Is there a “go-to” CCB?

Yes, generally rely on amlodipine. It’s the longest-acting dihydropyridine, causes less tachycardia and has more data for improving CV outcomes in hypertension.

• Keep in mind, peripheral edema is common with dihydropyridines. But don’t jump to a diuretic for CCB-induced edema, it’s due to fluid “leaking” out of blood vessels, not sodium or water retention.
• In this case, try reducing the CCB dose. Or consider adding an ACEI or ARB if more BP lowering is needed, this might counteract edema.

Is there a “best” thiazide?

No, there’s not a clear winner. Chlorthalidone is preferred in some BP guidelines because it shows CV benefit in key hypertension studies. And data suggest indapamide reduces CV risk versus placebo in patients aged 80 and up. This MIGHT be because chlorthalidone or indapamide lasts longer, and lowers BP slightly more, than hydrochlorothiazide. But recent data don’t find benefit with chlorthalidone over hydrochlorothiazide and suggest chlorthalidone causes more hypokalemia. And some experts believe ANY thiazide will have CV benefits as long as it controls BP, especially in combo with other BP meds. Evaluate what’s practical. For many patients, consider hydrochlorothiazide. It comes in many combos, if needed and costs slightly less than chlorthalidone or indapamide. Use our resource, "Overview of hypertension", for help with educating about diagnosis of HTN, lifestyle changes, pharmacotherapy and more.

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References

1. Chen R, Suchard MA, Krumholz HM, et al. Comparative First-Line Effectiveness and Safety of ACE (Angiotensin-Converting Enzyme) Inhibitors and Angiotensin Receptor Blockers: A Multinational Cohort Study. Hypertension. 2021;78(3):591-603.
2. Whelton PK, Carey RM. The 2017 Clinical Practice Guideline for High Blood Pressure. JAMA. 2017;318(21):2073-2074.
3. Ishani A, Cushman WC, Leatherman SM, et al. Chlorthalidone vs. Hydrochlorothiazide for Hypertension-Cardiovascular Events. N Engl J Med. 2022;387(26):2401-2410.

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