Management of Hypertension with Oral Drugs

Initial Assessment and Treatment

For most adults with confirmed hypertension ≥140/90 mmHg, initiate pharmacologic therapy immediately alongside lifestyle modifications using a single first-line agent, but if blood pressure is ≥160/100 mmHg, start with two agents simultaneously, preferably as a single-pill combination, as recommended by the American Heart Association 1, 2
Confirm hypertension using out-of-office measurements—either home blood pressure monitoring (≥135/85 mmHg) or 24-hour ambulatory monitoring (≥130/80 mmHg)—rather than relying solely on office readings before initiating treatment, according to the American College of Cardiology 1, 2

Implement a DASH-style eating pattern emphasizing 8-10 servings/day of fruits and vegetables, 2-3 servings/day of low-fat dairy products, and reduced saturated/trans fats, as suggested by the American Diabetes Association 3, 1
Restrict sodium intake to <2,300 mg/day (ideally <1,500 mg/day), as recommended by the American Heart Association 1, 2
Increase potassium intake through dietary sources (3,500-5,000 mg/day), according to the American College of Cardiology 1, 4

Start with a single antihypertensive agent from first-line options: ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers, as recommended by the American College of Cardiology 3, 5, 1
For blood pressure ≥160/100 mmHg, initiate pharmacologic treatment with two antihypertensive medications simultaneously from different classes, preferably as a single-pill combination, according to the American Heart Association 3, 5, 1, 2

For patients with diabetes, use ACE inhibitor or ARB as first-line therapy to reduce risk of progressive kidney disease, as recommended by the American Diabetes Association 3, 5, 1
For patients with chronic kidney disease or albuminuria, initial treatment should include an ACE inhibitor or ARB at the maximum tolerated dose to reduce risk of progressive kidney disease, according to the National Kidney Foundation 5, 1, 2

Recheck blood pressure in 1 month after initiating therapy, as recommended by the American College of Cardiology 1, 2
If starting with monotherapy, titrate to full dose of initial agent before adding a second drug, according to the American Heart Association 1, 2

Ensure the three-drug regimen includes a diuretic and consists of an ACE inhibitor/ARB, calcium channel blocker, and thiazide diuretic, as recommended by the American College of Cardiology 3, 2
Consider adding mineralocorticoid receptor antagonist for patients not meeting blood pressure targets on three classes of antihypertensive medications including a diuretic, according to the American Heart Association 3, 5, 2

Monitor serum creatinine/estimated glomerular filtration rate and serum potassium levels 7-14 days after starting or adjusting doses of ACE inhibitors, ARBs, or diuretics, then at least annually, as recommended by the National Kidney Foundation 5, 1, 2
Watch for hypokalemia when using diuretics, according to the American College of Cardiology 1, 2

Target blood pressure of <130/80 mmHg for most adults <65 years, as recommended by the American College of Cardiology 1
Target systolic <130 mmHg if well-tolerated for adults ≥65 years, according to the American Heart Association 1
For patients with diabetes, chronic kidney disease, or established cardiovascular disease, target <130/80 mmHg, as recommended by the American Diabetes Association 1