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Antihypertensives: Drug Dosing and Interactions with ARVs

for Health Care Providers

Table 2. Antihypertensives: Drug Dosing and Interactions with ARVs

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Generic Drug NameUsual Starting Dosage/Dosage TitrationComments/Drug Interactions
Thiazide Diuretics
  • Pros: Cardioprotective in ALLHAT study; first-line therapy in JNC 7, VA/DoD guidelines. Thiazide diuretics and CCBs may be more effective than other antihypertensives for African American patients.
  • Cons: Risk of hypokalemia. Monitor electrolytes periodically. Other potential adverse effects include rash, hyperglycemia, sexual dysfunction, and frequent urination. Should not be given to patients with a history of gout, as they may trigger attacks.
ChlorthalidoneStart at 12.5-25 mg QD; may increase up to 50 mg QD; dosages >50 mg carry risk of hypokalemia without added benefit
Hydrochlorothiazide (HCTZ)Start at 12.5-25 mg QD; may increase up to 50 mg QD (dosages >25 mg carry risk of hypokalemia with limited added benefit)
Beta-Blockers (BBs)
  • Pros: Useful for patients with concomitant CAD, CHF, previous MI, or those in need of rate control owing to atrial fibrillation or flutter.
  • Cons: May be associated with increased risk of stroke (particularly in smokers) and insulin resistance. When discontinuing, taper over course of 14 days to avoid rebound hypertension, angina, MI, or arrhythmia. May be less effective for patients without CAD, especially elderly patients. Use with caution in patients with reactive airway disease. Potential adverse effects include bradycardia, hypotension, fatigue, and sexual dysfunction.
AtenololStart at 25-50 mg QD or divided BID; maximum 100 mg per dayATV may ↑ atenolol concentrations; no dosage adjustment appears to be necessary.
MetoprololStart at 50 mg BID; maximum 225 mg BIDCYP 2D6 substrate; PIs may ↑ metoprolol levels.
Metoprolol Extended ReleaseStart at 50-100 mg QD; maximum 400 mg QDCYP 2D6 substrate; PIs may ↑ metoprolol levels.
PropranololStart at 20 mg BID; maximum 640 mg per day in divided doses
Propranolol Extended ReleaseStart at 60 mg QD; maximum 640 mg QDExtended-release formulation cannot be substituted for immediate-release form on a mg per mg basis; may require dosage change.
Mixed Alpha-/Beta-Blockers
  • Pros: Useful for patients with known CAD or CHF.
  • Cons: Same as for BBs. Avoid in patients with decompensated heart failure who are dependent on sympathetic stimulation.
CarvedilolStart at 6.25 mg BID; titrate slowly; usual dosage: 12.5-50 mg/day, divided BIDCYP 2D6 substrate; PIs may ↑ carvedilol levels.
LabetalolUsual dosage: 200-800 mg/day, divided BIDIV form useful in hypertensive emergencies.
ACE Inhibitors
  • Pros: Cardioprotective, renal protective.
  • Cons:Avoid during pregnancy; use with caution in patients who are elderly, are fluid depleted, or have renal insufficiency. Risk of hyperkalemia. Check electrolytes 1 week after starting ACEI. Other potential adverse effects include angioedema, cough, renal insufficiency, and sexual dysfunction.
BenazeprilStart at 10 mg QD; maximum 80 mg per day; usual dosage: 20-40 mg QD or divided BID; may need BID dosing for continuous BP controlStart at 5 mg QD if patient is elderly, has renal insufficiency, or is taking a diuretic.
FosinoprilStart at 10 mg QD; maximum 80 mg per day, but no additional effect over 40 mg per day; usual dosage: 10-40 mg QD or divided BID; BID dosing may be needed for continuous BP controlStart at 5 mg QD if patient is elderly, has renal insufficiency, or is taking a diuretic.
LisinoprilStart at 10 mg QD; maximum 80 mg QD but no additional effect over 40 mg per day; usual dosage: 20-40 mg QDStart at 2.5-5 mg QD if patient is elderly, has renal insufficiency, or is taking a diuretic.
RamiprilStart at 2.5 mg QD; maximum 20 mg QD; usual dosage: 2.5-20 mg QD or divided BID; may need BID dosing for continuous BP controlStart at 1.25 mg QD if patient is elderly, has renal insufficiency, or is taking a diuretic.
Angiotensin Receptor Blockers (ARBs)
  • Pros: Cardioprotective, renal protective.
  • Cons:Avoid during pregnancy; use with caution in patients who are elderly, are fluid depleted, or have renal insufficiency. Risk of hyperkalemia. Other potential adverse effects include angioedema and renal dysfunction.
CandesartanUsual starting dosage: 16 mg QD, may be divided BID; maximum 32 mg per dayStart at lower dosage in patients with moderate or worse hepatic impairment, volume depletion.
IrbesartanStart at 150 mg QD; maximum 300 mg QDStart at 75 mg QD for patients with volume depletion.
LosartanStart at 50 mg QD; maximum 100 mg QD or divided BIDStart at 25 mg QD for patients with volume depletion or hepatic insufficiency.
TelmisartanUsual starting dosage: 40 mg QD; maximum 80 mg QDStart at 20 mg QD in elderly, patients with hepatic impairment or volume depletion; monitor closely.
ValsartanStart at 80 mg QD; maximum 320 mg QD
Calcium Channel Blockers (CCBs)
  • Pros: CCBs and thiazide diuretics may be more effective than other antihypertensives for African American patients.
  • Cons: Metabolism of CCBs is inhibited by PIs; if CCBs must be used with PIs, reduce initial dosage and titrate up while monitoring for side effects (eg, hypotension, conduction block, bradycardia, and peripheral edema). Metabolism of CCBs may be induced by the NNRTIs EFV and NVP, leading to blunted antihypertensive effect.
  • Avoid immediate-release forms. Avoid in patients with CHF.
AmlodipineStart at 2.5 mg QD; maximum 10 mg dailySee Cons above.
Diltiazem Sustained ReleaseStart at 60 mg BID; maximum 360 mg per day in divided doses
Diltiazem Extended ReleaseStart at 120 mg QD; maximum 540 mg QD
Nifedipine Extended ReleaseStart at 30 mg QD; maximum 120 mg QD
Verapamil Sustained ReleaseStart at 120 mg QD; maximum 480 mg per day, but divide BID if using >240 mg per dayImmediate-release formulation is not recommended for treatment of hypertension.
Verapamil Extended Release
  • Covera HS: Start at 180 mg QHS; maximum 480 mg QHS
  • Verelan PM: start at 100 mg QHS; maximum 400 mg QHS
Immediate-release formulation is not recommended for treatment of hypertension.
Potassium-Sparing Diuretics and Aldosterone Antagonists
  • Pros: Indicated in CAD, and CHF with EF <40%, class IV heart failure. May be useful in patients with hypokalemia; often combined with a thiazide diuretic.
  • Cons: May cause hyperkalemia: monitor K+
SpironolactoneUsual dosage is 50 mg to 100 mg QD or divided BID
  • Monitor for hyperkalemia; check K+ 1 week after starting spironolactone.
  • Potential adverse effects include liver toxicity, gynecomastia, and sexual dysfunction.
TriamtereneStart at 100 mg BID; maximum daily dosage is 300 mgMonitor for hyperkalemia; check K+ 1 week after starting triamterene.
Direct Vasodilators and Anti-Adrenergic Agents
  • (Note: Alpha-blockers used for treatment of benign prostatic hypertrophy are not recommended as monotherapy for hypertension; however, these may cause hypotension especially in patients who are taking other antihypertensive medications.)
Clonidine
  • PO: Start at 0.1 mg BID; increase to usual maintenance dosage of 0.2-1.2 mg divided BID to TID; maximum 2.4 mg in divided doses
  • Patch: Start at 0.1 mg/24-hour patch, increasing to desired effect; maximum dosage is 0.6 mg/24-hour patch
Possible adverse effects include bradycardia, sedation. Risk of rebound hypertension upon discontinuation: taper over course of 7 days.
HydralazineStart at 25 mg BID; increase by 10-25 mg/dose to effective dosage; may divide effective daily dosage BID; maximum 200 mg per day in divided dosesPossible adverse effects include lupus-like syndrome, requiring discontinuation (increased risk at higher dosages). May cause reflex tachycardia; use with caution in patients with CAD.
DoxazosinStart at 1 mg QHS; maximum 16 mg per dayNot a first-line agent. Possible adverse effects include risk of CHF, dizziness, postural hypotension, drowsiness, and syncope; all more likely if doxazosin is given with other vasodilators, including PDE-5 inhibitors. Risk of syncope with initial dosages; start at lowest dose QHS. If drug is interrupted, restart at 1 mg QHS dosing.
PrazosinStart at 1 mg BID or TID; usual maintenance dosage 20 mg/day divided BID or TID; maximum 40 mg divided BID or TIDNot a first-line agent. Possible adverse effects include risk of CHF, dizziness, postural hypotension, drowsiness, and syncope; all more likely if prazosin is given with other vasodilators, including PDE-5 inhibitors. Risk of syncope with initial dosages; start at lowest dose QHS. If drug is interrupted, restart at 1 mg QHS.
TerazosinStart at 1 mg QHS; usual daily dosage 1-5 mg QD or divided BID; maximum 20 mg per dayNot a first-line agent. Possible adverse effects include risk of CHF, dizziness, postural hypotension, drowsiness, and syncope; all more likely if terazosin is given with other vasodilators, including PDE-5 inhibitors. Risk of syncope with initial dosages; start at lowest dosage QHS. If drug is interrupted, restart at 1 mg QHS dosing.

From Hypertension
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009