What is BP medication types and how mg per day maximum and which comorbidities are avoided and alternative with mg
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Blood Pressure (Antihypertensive) Medication Types
Based on the 2024 ESC Guidelines, 2025 AHA/ACC Guidelines, and clinical pharmacology references, here is a complete breakdown by drug class.
Note: The 2025 AHA/ACC guideline (PMID 40811516) is the most current major guidance. The 2024 ESC guidelines (PMID 39210715) now formally recognize SGLT2 inhibitors as adjuncts in CKD/HF/diabetes patients.
1. ACE Inhibitors (ACEi)
Mechanism: Block conversion of angiotensin I to angiotensin II → vasodilation, reduced aldosterone
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Lisinopril | 10 mg/day | 40 mg/day |
| Enalapril | 5 mg/day | 40 mg/day |
| Ramipril | 2.5 mg/day | 20 mg/day |
| Captopril | 12.5 mg TID | 150 mg/day |
| Quinapril | 10-20 mg/day | 40 mg/day |
| Benazepril | 10 mg/day | 40 mg/day |
| Perindopril | 4 mg/day | 16 mg/day |
| Trandolapril | 1 mg/day | 8 mg/day |
Avoid in (contraindications):
- Pregnancy (teratogenic - causes fetal harm)
- History of angioedema (ACEi-related)
- Bilateral renal artery stenosis
- Hyperkalemia (K+ > 5.5 mEq/L)
- Concurrent use with ARBs or ARNi (sacubitril/valsartan) - wait 36 hours
- Concurrent aliskiren in diabetics
Favored comorbidities (preferred use): Diabetes with nephropathy, CKD with proteinuria, post-MI, heart failure with reduced EF (HFrEF), CAD
Alternative if ACEi not tolerated: Switch to ARB (avoids dry cough, same efficacy)
2. Angiotensin Receptor Blockers (ARBs)
Mechanism: Directly block angiotensin II at AT1 receptor
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Losartan | 50 mg/day | 100 mg/day |
| Valsartan | 80-160 mg/day | 320 mg/day |
| Irbesartan | 150 mg/day | 300 mg/day |
| Candesartan | 8-16 mg/day | 32 mg/day |
| Olmesartan | 20 mg/day | 40 mg/day |
| Telmisartan | 40 mg/day | 80 mg/day |
| Eprosartan | 600 mg/day | 800 mg/day |
Avoid in:
- Pregnancy (same fetal risk as ACEi)
- Concurrent ACEi use (increases renal/CV adverse events)
- Concurrent aliskiren in diabetics
- Hyperkalemia, bilateral renal artery stenosis
Favored comorbidities: Same as ACEi; preferred when ACEi-cough is problematic
Alternative if ARB not tolerated: ACEi (if no prior angioedema); or CCB + diuretic combination
3. Calcium Channel Blockers (CCBs)
Dihydropyridines (DHP) - primarily vasodilatory
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Amlodipine | 2.5-5 mg/day | 10 mg/day |
| Nifedipine XL | 30 mg/day | 90-120 mg/day |
| Felodipine | 2.5-5 mg/day | 20 mg/day |
| Lercanidipine | 10 mg/day | 20 mg/day |
| Nitrendipine | 10 mg/day | 20 mg/day |
Avoid in:
- Advanced heart failure (negative inotrope)
- Peripheral edema (existing severe)
- Caution in severe liver disease (amlodipine)
Favored comorbidities: Elderly, isolated systolic hypertension, angina, Raynaud's, Black patients
Non-Dihydropyridines (non-DHP) - cardiac depressant
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Diltiazem ER | 180-240 mg/day | 480 mg/day |
| Verapamil ER | 120-180 mg/day | 480 mg/day |
Avoid in:
- Heart block (2nd/3rd degree AV block without pacemaker)
- Concurrent beta-blocker use (risk of complete heart block, bradycardia)
- HFrEF / systolic heart failure
- Sick sinus syndrome
Alternative: DHP-CCB (e.g., amlodipine) if non-DHP contraindicated
4. Thiazide / Thiazide-like Diuretics
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Hydrochlorothiazide (HCTZ) | 12.5-25 mg/day | 50 mg/day |
| Chlorthalidone | 12.5-25 mg/day | 50 mg/day |
| Indapamide | 1.25 mg/day | 2.5 mg/day |
Avoid in:
- eGFR/CrCl < 30 mL/min (HCTZ ineffective; chlorthalidone may still work at lower doses)
- Symptomatic gout (worsen hyperuricemia)
- Pregnancy (can cause electrolyte imbalances in neonate)
- Sulfonamide allergy (relative, especially arylamine-containing)
- Pre-existing severe hypokalemia
Favored comorbidities: Elderly, osteoporosis (hypercalciuric effect), heart failure, isolated systolic HTN
Alternative if thiazide not tolerated: Loop diuretic (furosemide) for CKD/edema; potassium-sparing diuretic (spironolactone) for resistant HTN
5. Beta-Blockers
Generations:
- 1st gen (non-selective): Propranolol, nadolol, timolol
- 2nd gen (β1-selective): Metoprolol, atenolol, bisoprolol, esmolol
- 3rd gen (with vasodilation): Carvedilol (α+β), labetalol (α+β), nebivolol (β1 + NO-mediated)
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Metoprolol succinate | 25-50 mg/day | 200 mg/day |
| Metoprolol tartrate | 25 mg BID | 200 mg/day |
| Atenolol | 25-50 mg/day | 100 mg/day |
| Bisoprolol | 2.5-5 mg/day | 20 mg/day |
| Carvedilol | 3.125 mg BID | 50 mg/day (< 85 kg); 100 mg/day (> 85 kg) |
| Labetalol | 100 mg BID | 1200 mg/day (oral) |
| Propranolol | 40 mg BID | 320 mg/day |
| Nebivolol | 5 mg/day | 40 mg/day |
Avoid in:
- Asthma (non-selective BBs absolutely; cardioselective with caution)
- Severe COPD (use cardioselective only with caution)
- 2nd/3rd degree AV block (without pacemaker)
- Bradycardia (HR < 60 bpm)
- Concurrent non-DHP CCB (diltiazem or verapamil) - risk of complete block
- Peripheral arterial disease (relative)
- Metabolic syndrome / high diabetes risk (increase new-onset T2DM risk, especially non-selective)
- Atenolol should be avoided in pregnancy (fetal growth restriction)
Favored comorbidities: Post-MI, HFrEF (carvedilol/bisoprolol/metoprolol succinate specifically), atrial fibrillation (rate control), angina, hyperthyroidism, migraine prophylaxis, essential tremor
Alternative if beta-blocker contraindicated: For rate control in AF → use non-DHP CCB (diltiazem/verapamil); for HFrEF → evidence-based BBs only; for HTN alone → ACEi/ARB + CCB preferred first-line
6. Potassium-Sparing Diuretics / Aldosterone Antagonists
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Spironolactone | 25-100 mg/day | 100 mg/day (HTN); higher in heart failure |
| Eplerenone | 50 mg/day | 100 mg/day |
| Triamterene/HCTZ | 37.5/25 mg/day | 75/50 mg/day |
| Amiloride | 5 mg/day | 20 mg/day |
Avoid in:
- CrCl < 10-30 mL/min (risk of life-threatening hyperkalemia)
- Hyperkalemia (K+ > 5.0 mEq/L)
- Concurrent ACEi + ARB combination (triple RAAS blockade - dangerous)
- Spironolactone: avoid in severe liver failure
Favored comorbidities: Resistant HTN (add-on therapy), primary hyperaldosteronism, heart failure (post-MI LV dysfunction), cirrhosis with ascites
Alternative: Eplerenone (more selective, fewer hormonal side effects like gynecomastia vs. spironolactone)
7. Alpha-1 Blockers
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Doxazosin | 1 mg/day | 16 mg/day |
| Terazosin | 1 mg/day | 20 mg/day |
| Prazosin | 1 mg BID-TID | 20 mg/day |
Avoid in:
- Orthostatic hypotension (risk of severe first-dose hypotension)
- History of syncope
- Not recommended as monotherapy for HTN (increased HF risk vs. other classes - ALLHAT trial)
Favored comorbidities: Benign prostatic hyperplasia (BPH), pheochromocytoma
Alternative: ACEi/ARB or CCB for primary HTN; alpha-blockers used as add-on
8. Centrally Acting Agents
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Clonidine | 0.1 mg BID | 2.4 mg/day |
| Methyldopa | 250 mg BID-TID | 3000 mg/day |
| Rilmenidine | 1 mg/day | 2 mg/day |
Avoid in:
- Clonidine: abrupt discontinuation causes rebound hypertension; avoid in severe CAD
- Methyldopa: active liver disease, hemolytic anemia
- Sedation limits use in active patients
Favored comorbidities: Methyldopa is the preferred antihypertensive in pregnancy; clonidine useful in hypertensive urgency
9. Loop Diuretics
| Drug | Starting Dose | Max Daily Dose |
|---|---|---|
| Furosemide | 20-40 mg/day | 600 mg/day (edematous states) |
| Bumetanide | 0.5-1 mg/day | 10 mg/day |
| Torsemide | 5-10 mg/day | 200 mg/day |
Avoid in: Severe hypokalemia, dehydration, anuric renal failure
Favored comorbidities: CKD with fluid overload, heart failure with edema (thiazides lose efficacy at low GFR)
10. SGLT2 Inhibitors (Newer - 2024 ESC Class I Recommendation)
| Drug | Dose | Max Daily Dose |
|---|---|---|
| Empagliflozin | 10 mg/day | 25 mg/day |
| Dapagliflozin | 10 mg/day | 10 mg/day |
| Canagliflozin | 100 mg/day | 300 mg/day |
Avoid in: eGFR < 20 mL/min, recurrent UTIs/genital infections, type 1 diabetes (DKA risk), active foot ulcers
Favored comorbidities: HTN + T2DM, CKD, HFrEF, HFpEF - dual CV/renal protection
Quick Summary: Comorbidity-Driven Drug Selection
| Comorbidity | Preferred Drug(s) | Avoid |
|---|---|---|
| Diabetes + nephropathy | ACEi or ARB, SGLT2i | Thiazides (high dose worsens glycemia) |
| Heart failure (HFrEF) | ACEi/ARB + carvedilol/bisoprolol/metoprolol succinate + spironolactone | Non-DHP CCBs, alpha-1 blockers |
| Post-MI | Beta-blocker + ACEi/ARB | Non-DHP CCBs alone |
| Asthma/COPD | ACEi (caution: cough), CCB, ARB | Non-selective beta-blockers |
| Pregnancy | Methyldopa, labetalol, nifedipine | ACEi, ARBs (teratogenic), atenolol |
| Gout | ACEi, ARB, CCB | Thiazides (worsen uric acid) |
| Atrial fibrillation | Beta-blocker or non-DHP CCB (rate control) | Avoid combining BB + non-DHP CCB |
| BPH | Doxazosin (terazosin) | N/A |
| Bilateral renal artery stenosis | CCB, beta-blocker | ACEi, ARBs (risk of renal failure) |
| AV block (2nd/3rd degree) | CCB (DHP only), ACEi, ARBs | Non-DHP CCBs, beta-blockers |
| Osteoporosis | Thiazides (calcium-retaining) | Loop diuretics (calcium-wasting) |
| Resistant HTN (on 3 drugs) | Add spironolactone (eplerenone) | Avoid triple RAAS blockade |
Key Guideline Takeaway (2025 AHA/ACC + 2024 ESC): First-line treatment for most patients is a combination of ACEi or ARB + CCB + thiazide-like diuretic. Beta-blockers are no longer first-line for uncomplicated HTN but remain preferred when a specific comorbidity (HF, post-MI, AF, angina) is present. SGLT2 inhibitors now have a Class I recommendation in HTN with CKD, T2DM, or HF.
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