Hypertension Management

Initial Treatment

For patients with hypertension, the American Diabetes Association recommends initiating treatment with ACE inhibitors (IECA), angiotensin receptor blockers (BRA), thiazide diuretics, or dihydropyridine calcium channel blockers, with selection based on patient comorbidities 1, 2
The initial blood pressure target is <140/90 mmHg for most adults, with consideration of comorbidities such as diabetes, coronary artery disease, or chronic kidney disease 2, 3
For patients with blood pressure 140/90 - 159/99 mmHg, monotherapy is recommended, while those with blood pressure ≥160/100 mmHg should start with combination therapy of two medications 1, 2, 3

For patients with diabetes and albuminuria (UACR ≥30 mg/g creatinine), the American Diabetes Association recommends ACE inhibitors or angiotensin receptor blockers as first-line treatment, with maximum tolerated dose for those with UACR ≥300 mg/g 1, 2, 3
For patients with coronary artery disease, ACE inhibitors or angiotensin receptor blockers are recommended as first-line treatment, with beta blockers considered for those with active angina or post-myocardial infarction 2, 4
For patients with heart failure, ACE inhibitors or angiotensin receptor blockers are recommended for those with reduced ejection fraction, while diuretics are recommended for those with preserved ejection fraction and volume overload 5
For patients with chronic kidney disease, ACE inhibitors or angiotensin receptor blockers are recommended as first-line treatment 5

If blood pressure target is not achieved with initial monotherapy, the dose should be increased or a second medication from a different class should be added 2, 6
If blood pressure remains elevated with two medications, a third medication (usually a diuretic if not already included) should be added 2, 6
For patients with resistant hypertension (blood pressure ≥140/90 mmHg despite three medications including a diuretic), consideration should be given to adding a mineralocorticoid receptor antagonist 1, 2, 3

Patients treated with ACE inhibitors, angiotensin receptor blockers, or diuretics should have serum creatinine/estimated glomerular filtration rate and potassium levels monitored at least annually 1, 3
Fixed-dose combinations in a single pill may improve adherence to treatment 2
Lifestyle modifications, including sodium restriction, potassium supplementation, weight loss, regular physical activity, moderate alcohol consumption, and a DASH diet rich in fruits and vegetables, should always be recommended alongside pharmacological therapy 3, 4

Combinations of ACE inhibitors with angiotensin receptor blockers or direct renin inhibitors should be avoided due to increased risk of adverse effects 3