Hypertension Management

Initial Medication Therapy

For patients with confirmed hypertension, initial medication therapy should include a thiazide-like diuretic, ACE inhibitor, ARB, or calcium channel blocker, with specific choices based on patient characteristics and comorbidities, as recommended by the American Diabetes Association and other guideline societies 1, 2, 3
The American College of Cardiology recommends starting with a single antihypertensive agent for patients with blood pressure 140/90 - 159/99 mmHg 3
For patients with blood pressure ≥160/100 mmHg, the American College of Cardiology recommends initiating with two antihypertensive medications simultaneously (either as separate agents or fixed-dose combination) 3, 4

For Black patients, the first choice of medication should be a thiazide-like diuretic or calcium channel blocker, as recommended by the American College of Cardiology and the Mayo Clinic 4, 5
For patients with albuminuria (UACR ≥30 mg/g), the first choice of medication should be an ACE inhibitor or ARB, with a maximum tolerated dose recommended by the American Diabetes Association 1
For patients with diabetes and coronary artery disease, the first choice of medication should be an ACE inhibitor or ARB, as recommended by the American Diabetes Association 1
For patients without specific indications, any of the four major classes (thiazide diuretic, ACE inhibitor, ARB, or CCB) can be used, as recommended by the American Diabetes Association and other guideline societies 2, 3

The dose of medication should be titrated upward if blood pressure goal is not achieved within 2-4 weeks, as recommended by the Mayo Clinic 5
Serum creatinine, eGFR, and potassium levels should be monitored at least annually for patients on ACE inhibitors, ARBs, or diuretics, as recommended by the American Diabetes Association 1

When monotherapy is insufficient, combination therapy with a thiazide diuretic + ACE inhibitor or ARB, or a calcium channel blocker + ACE inhibitor or ARB, or a calcium channel blocker + thiazide diuretic can be used, as recommended by the American Diabetes Association and other guideline societies 2
However, combining an ACE inhibitor with an ARB should be avoided due to increased risk of adverse effects without additional cardiovascular benefit, as warned by the American Diabetes Association 3

For resistant hypertension (BP not controlled on three drugs including a diuretic), the preferred combination is a CCB + thiazide diuretic + ACE inhibitor or ARB, as recommended by the American Diabetes Association 1, 2
A mineralocorticoid receptor antagonist can be considered as fourth-line therapy, as recommended by the American Diabetes Association 1

Long-acting agents like chlorthalidone and indapamide are preferred, as recommended by the American Diabetes Association 1
Patients on ACE inhibitors, ARBs, or diuretics should be monitored for hyperglycemia, hyperuricemia, and electrolyte disturbances, as recommended by the European Heart Journal 6
ACE inhibitors are contraindicated in pregnancy and may provide additional benefit in patients with proteinuria or heart failure, as recommended by the European Heart Journal 6, 7
ARBs have similar efficacy to ACE inhibitors with a better tolerability profile, but are contraindicated in pregnancy, as recommended by the European Heart Journal 6
Dihydropyridine CCBs (e.g., amlodipine) are preferred for hypertension, as recommended by the American Diabetes Association 1

Inappropriate combination therapy, such as combining ACE inhibitors with ARBs, should be avoided, as warned by the American Diabetes Association 3
Inadequate monitoring of renal function and electrolytes in patients on ACE inhibitors, ARBs, or diuretics should be avoided, as recommended by the American Diabetes Association 1
Delayed intensification of therapy should be avoided, and a second agent should be added if BP remains uncontrolled, as recommended by the American College of Cardiology 4
Overlooking secondary causes of hypertension, such as medication nonadherence, white coat hypertension, and secondary hypertension, should be avoided, as recommended by the American Diabetes Association 1
Discontinuing effective therapy should be avoided, and the current regimen should be continued if BP is below target without adverse effects, as recommended by the Mayo Clinic 5