Anti-hypertensive drugs in children and adolescents

Table 1 Anti-hypertensive class effects

Drug class	Special indications	Precautions	Contraindications	Common adverse events
Angiotensin converting enzymeinhibitors	Proteinuria Chronic kidney disease	Less efficacious in blacks Risk of angioedema, increase risk of hyperkalemia Decreased glomerular filtration rate	Prior history of angioedema with use of ACE inhibitor Discontinue if pregnant: Pregnancy class C in 1st trimester, pregnancy class D in 2nd and 3rd trimester	Headache Dizziness Abdominal pain Nausea Cough
Angiotensin receptor blockers	Proteinuria	Less efficacious in blacks Increase risk of hyperkalemia Decreased GFR	Discontinue if pregnant: Pregnancy class C in 1st trimester, pregnancy class D in 2nd and 3rd trimester	Headache Dizziness Cough
Calcium channel blockers	None	Drug interactions with compounds that change cytochrome P450s metabolism (i.e.: Azole antifungals, grapefruit juice, anti-seizure medications)	Pregnancy class C	Headache Peripheral edema Fatigue Dizziness Abdominal pain Epistaxis
Beta blockers	None	Increased risk of bronchoconstriction in asthma	Severe bradycardia Heart block greater than first degree Cardiogenic shock Decompensated cardiac failure	Headache Cough Nasopharyngitis Fatigue Diarrhea Dizziness

Pregnancy class C: Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks; Pregnancy class D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks; ACE: Angiotensin converting enzyme.

Table 2 Anti-hypertensive drugs that have been studied in pediatric clinical trials for United States Food and Drug Administration labeling

Drug class	Drug	Starting dose	Max dose	Frequency	Suspension formulation	Pediatric indication
Angiotensin converting enzyme inhibitor	Enalapril	0.08 mg/kg (up to 5 mg)	0.58 mg/kg or 40 mg	Daily	Yes	All except neonates
	Fosinopril	0.1 mg/kg (5-10 mg)	0.6 mg/kg or 40 mg	Daily	No	Children > 50 kg
	Lisinopril	0.07 mg/kg (up to 5 mg)	0.6 mg/kg or 40 mg	Daily	Yes	> 6 yr
	Benazepril	0.2 mg/kg (up to 10 mg)	0.6 mg/kg or 40 mg	Daily	Yes	>6 yr
Angiotensin receptor blocker	Losartan	0.7 mg/kg (up to 50 mg)	1.4 mg/kg or 100 mg	Daily	Yes	> 6 yr
	Valsartan	1.3 mg/kg (up to 40 mg)	2.7 mg/kg or 160 mg	Daily	Yes	> 6 yr
	Candesartan	1-6 yr: 0.2 mg/kg	1-6 yr: 0.4 mg/kg	Daily or divided dose	Yes	> 1 yr
		6-17 yr, < 50 kg: 4 mg	6-17 yr, < 50 kg: 16 mg
		6-17 yr, > 50 kg 8 mg	6-17 yr, > 50 kg 32 mg
	Olmesartan	20 to < 35 kg: 10 mg	20 to < 35 kg: 20 mg	Daily	Yes	> 6 yr
		≥ 35 kg: 20 mg	≥ 35 kg: 40 mg
	Irbesartan	No FDA pediatric indication (efficacy not demonstrated)
Beta blocker	Metoprolol XL	1.0 mg/kg (< 50 mg)	2 mg/kg up to 200 mg	Daily	No	> 6 yr
	Bisoprolol	No FDA pediatric indication (efficacy not demonstrated)
Calcium channel blocker	Amlodipine	2.5 mg	0.3 mg/kg or 10 mg	Daily	No	> 6 yr
	Felodipine	No FDA pediatric indication (efficacy not demonstrated)
Diuretic	Eplerenone	No FDA pediatric indication (efficacy not demonstrated)

FDA: Food and Drug Administration.

Table 3 Other commonly used “off-label” antihypertensive drugs¹

Drug class	Drug	Starting dose	Max dose	Frequency
Angiotensin converting enzyme inhibitor	Captopril	0.3-0.5 mg/kg per dose	6 mg/kg up to 450 mg/d	Two to three times daily
Beta blocker	Atenolol	0.5 mg/kg per day	2 mg/kg per day up to 100 mg	Once to twice daily
	Propranolol	1 mg/kg per day	16 mg/kg per day up to 640 mg	Two to four times daily
Calcium channel blocker	Extended release nifedipine	0.25 mg/kg per day	3 mg/kg per day up 120 mg/kg per day	Once to twice daily
Diuretic	Furosemide	0.5 mg/kg per dose	6 mg/kg per dose	Twice to three times daily
	Hydrochlorothiazide	0.5-1 mg/kg	3 mg/kg up to 50 mg	Daily

¹These drugs have not been well studied in pediatric clinical trials and dosing/safety/efficacy are largely extrapolated from trials in adults.