First-Line Treatments for Hypertension

Lifestyle Modifications

The American Diabetes Association recommends weight loss for overweight or obese individuals with blood pressure >120/80 mmHg through caloric restriction 1
The American Diabetes Association suggests a DASH eating pattern with reduced sodium (<2,300 mg/day) and increased potassium intake for patients with blood pressure >120/80 mmHg 1
Regular physical activity (at least 150 minutes of moderate-intensity aerobic activity per week) is recommended for patients with blood pressure >120/80 mmHg 1
Moderation of alcohol consumption (≤2 drinks/day for men, ≤1 drink/day for women) is advised for patients with blood pressure >120/80 mmHg 1
Smoking cessation is recommended for all patients with blood pressure >120/80 mmHg 1

The American Diabetes Association recommends four primary classes of antihypertensive medications: ACE inhibitors, ARBs, thiazide-like diuretics, and dihydropyridine calcium channel blockers as first-line treatments for hypertension 1, 2, 3
ACE inhibitors (e.g., lisinopril) are recommended as a first-line medication class for people with hypertension 1, 2
Angiotensin Receptor Blockers (ARBs) are recommended as a first-line medication class for people with hypertension 1, 2
Thiazide-like diuretics (preferably long-acting agents like chlorthalidone or indapamide) are recommended as a first-line medication class for people with hypertension 1, 3
Dihydropyridine calcium channel blockers (e.g., amlodipine) are recommended as a first-line medication class for people with hypertension 1

For patients with BP between 130/80 mmHg and 150/90 mmHg, the American Diabetes Association recommends starting with a single drug 1, 3
For patients with BP ≥150/90 mmHg or ≥160/100 mmHg, the American Diabetes Association recommends initial treatment with two antihypertensive medications 1, 2

For patients with albuminuria (UACR ≥30 mg/g), the American Diabetes Association recommends ACE inhibitor or ARB as first-line therapy 1, 2
For patients with established coronary artery disease, the American Diabetes Association recommends ACE inhibitor or ARB as first-line therapy 1, 3
For black patients, the American Heart Association suggests that calcium channel blockers or thiazide diuretics may be more effective than ACE inhibitors or ARBs when used as monotherapy 4

The American Diabetes Association recommends monitoring serum creatinine and potassium levels when using ACE inhibitors, ARBs, or mineralocorticoid receptor antagonists 1, 2
The American Diabetes Association suggests monitoring for hypokalemia when using diuretics 1
Follow-up is recommended 7-14 days after initiation or dose changes of these medications 1
ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy and should be avoided in sexually active individuals of childbearing potential who are not using reliable contraception 1

The American Diabetes Association recommends starting with lifestyle modifications for all patients with BP >120/80 mmHg 1
For patients with BP 130/80-150/90 mmHg, the American Diabetes Association suggests beginning with a single agent from one of the four first-line classes 1, 3
For patients with BP ≥150/90 mmHg, the American Diabetes Association recommends starting with two medications (consider single-pill combinations to improve adherence) 1, 3

The American Diabetes Association advises against combining ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 2, 3
Single-pill combinations may improve medication adherence 1, 3
BP targets should generally be <130/80 mmHg for most adults, with individualization for elderly patients based on frailty 3, 5
Regular monitoring of kidney function and electrolytes is essential with many antihypertensive medications 1, 2