First line treatment for hypertension

Clinical answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 27 February 2026Updated: 27 February 2026 Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

First-line treatment for hypertension depends on the patient's age, ethnicity, and presence of type 2 diabetes.

  • Offer an ACE inhibitor or an angiotensin II receptor blocker (ARB) for adults starting step 1 antihypertensive treatment who are under 55 years old and not of Black African or African-Caribbean family origin, or any adult with type 2 diabetes regardless of age or ethnicity.
  • For adults aged 55 or over who do not have type 2 diabetes, and for adults of Black African or African-Caribbean family origin without type 2 diabetes (of any age), offer a calcium-channel blocker (CCB) as first-line treatment.
  • If the first-line agent is not tolerated (e.g., ACE inhibitor causing cough), offer an alternative class such as an ARB or a thiazide-like diuretic.
  • Do not combine an ACE inhibitor with an ARB.

These recommendations are based on NICE guidelines for hypertension management in adults .

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First line treatment for hypertension — Clinical answer | iatroX