TABLE 8-5

Antihypertensive Medications With Pediatric Experience

ClassDrugInitial DoseaMaximal DoseDosing IntervalEvidencebFDAcCommentsd
ACE inhibitorsBenazepril0.2 mg/kg per d up to 10 mg/d0.6 mg/kg per d up to 40 mg/dQDRCTYes1. All ACE inhibitors are contraindicated in pregnancy; women of childbearing age should use reliable contraception
Captopril0.3–0.5 mg/kg per dose (>12 mo)6 mg/kg per dTIDRCT, CSNo2. Check serum potassium and creatinine periodically to monitor for hyperkalemia and azotemia
3. Cough and angioedema are reportedly less common with newer members of this class than with captopril
FosinoprileChildren >50 kg: 5–10 mg/d40 mg/dQDRCTYes4. Benazepril, enalapril, and lisinopril labels contain information on the preparation of a suspension; captopril may also be compounded into a suspension
Lisinoprile0.07 mg/kg per d up to 5 mg/d0.6 mg/kg per d up to 40 mg/dQDRCTYes5. FDA approval for ACE inhibitors with pediatric labeling is limited to children ≥6 y of age and to children with creatinine clearance rate of ≥30 mL/min per 1.73 m2
Quinapril5–10 mg/d80 mg/dQDRCT, EONo6. Initial dose of fosinopril of 0.1 mg/kg per d may be effective, although black patients might require a higher dose
ARBsIrbesartan6–12 y: 75–150 mg/d; ≥13 y: 150–300 mg/d300 mg/dQDCSYes1. All ARBs are contraindicated in pregnancy; women of childbearing age should use reliable contraception
Losartane0.7 mg/kg per d up to 50 mg/d1.4 mg/kg per d up to 100 mg/dQD–BIDRCTYes2. Check serum potassium and creatinine levels periodically to monitor for hyperkalemia and azotemia
Valsartane5–10 mg/d; 0.4 mg/kg per d40–80 mg/d; 3.4 mg/kg per dQDRCTNo3. Losartan label contains information on the preparation of a suspension
4. FDA approval for ARBs is limited to children ≥6 y of age and to children with creatinine clearance rate of ≥30 mL/min per 1.73 m2
α- and β-antagonistLabetalol1–3 mg/kg per d10–12 mg/kg per d up to 1200 mg/dBIDCS, EONo1. Asthma and overt heart failure are relative contraindications
2. Heart rate is dose-limiting
3. May impair athletic performance in athletes
4. Should not be used in insulin-dependent diabetic patients
β-antagonistsAtenolol0.5–1 mg/kg per d2 mg/kg per d up to 100 mg/dQD–BIDCSNo1. Noncardioselective agents (propranolol) are contraindicated in asthma and heart failure
Bisoprolol/hydrochlorothiazide2.5–6.25 mg/d10/6.25 mg/dQDRCTNo2. Heart rate is dose-limiting
MetoprololeChildren >6 y: 1 mg/kg per d (12.5–50 mg/d)2 mg/kg per d up to 200 mg/dBIDCSYesf3. May impair athletic performance in athletes
Propranolol1–2 mg/kg per d4 mg/kg per d up to 640 mg/dBID–TIDRCT, EOYes4. Should not be used in insulin-dependent diabetic patients
5. A sustained-release, once-daily formulation of propranolol is available
Calcium-channel blockersAmlodipineeChildren 6–17 y: 2.5 mg/d5 mg/dQDRCTYes1. Amlodipine and isradipine can be compounded into stable extemporaneous suspensions
Felodipine2.5 mg/d10 mg/dQDRCT, EONo2. Felodipine and extended-release nifedipine tablets must be swallowed whole
Isradipine0.15–0.2 mg/kg per d0.8 mg/kg per d up to 20 mg/dTID–QIDCS, EONo3. Isradipine is available in both immediate- and sustained-release formulations; sustained release form is dosed QD or BID
Extended-release nifedipine0.25–0.5 mg/kg per d3 mg/kg per d up to 120 mg/dQD–BIDCS, EONo4. May cause tachycardia
5. Doses up to 10 mg of amlodipine have been evaluated in children
6. Contraindicated for children <1 y of age
Central α-agonistClonidineChildren ≥12 y: 0.2 mg/d2.4 mg/dBIDEOYes1. May cause dry mouth and/or sedation
2. Transdermal preparation is available
3. Sudden cessation of therapy can lead to severe rebound hypertension
DiureticsHydrochlorothiazide1 mg/kg per d3 mg/kg per d up to 50 mg/dQDEOYes1. All patients treated with diuretics should have their electrolytes monitored shortly after initiating therapy and periodically thereafter
Chlorthalidone0.3 mg/kg per d2 mg/kg per d up to 50 mg/dQDEONo2. Useful as add-on therapy in patients being treated with drugs from other drug classes
Furosemide0.5–2.0 mg/kg per dose6 mg/kg per dQD–BIDEONo3. Potassium-sparing diuretics (spironolactone, triamterene, amiloride) may cause severe hyperkalemia, especially if given with an ACE inhibitor or ARB
Spironolactone1 mg/kg per d3.3 mg/kg per d up to 100 mg/dQD–BIDEONo4. Furosemide is labeled only for treatment of edema but may be useful as add-on therapy in children with resistant hypertension, particularly in children with renal disease
Triamterene1–2 mg/kg per d3–4 mg/kg per d up to 300 mg/dBIDEONo5. Chlorthalidone may precipitate azotemia in patients with renal diseases and should be used with caution in those with severe renal impairment
Amiloride0.4–0.625 mg/kg per d20 mg/dQDEONo
Peripheral α-antagonistsDoxazosin1 mg/d4 mg/dQDEONo1. May cause first-dose hypotension
Prazosin0.05–0.1 mg/kg per day0.5 mg/kg per dTIDEONo
Terazosin1 mg/d20 mg/dQDEONo
VasodilatorsHydralazine0.75 mg/kg per d7.5 mg/kg per d up to 200 mg/dQIDEOYes1. Tachycardia and fluid retention are common adverse effects
MinoxidilChildren <12 y: 0.2 mg/kg per d;Children <12 y: 50 mg/d; childrenQD–TIDCS, EOYes2. Hydralazine can cause a lupus-like syndrome in slow acetylators
    children >12 y: 5 mg/d    ≥12 y: 100 mg/d3. Prolonged use of minoxidil can cause hypertrichosis
4. Minoxidil is usually reserved for patients with hypertension that is resistant to multiple drugs
  • ACE indicates angiotensin-converting enzyme; QD, every day; BID, 2 times daily; TID, 3 times daily; QID, 4 times daily; CS, case series; EO, expert opinion; ARB, angiotensin-receptor blocker.

  • a The maximal recommended adult dose should not be exceeded in routine clinical practice.

  • b Level of evidence on which recommendations are based.

  • c FDA-approved pediatric labeling information is available for treatment of hypertension. Recommended doses for agents with FDA-approved pediatric labels contained in this table are the doses contained in the approved labels. Even when pediatric labeling information is not available, the FDA-approved label should be consulted for additional safety information.

  • d Comments apply to all members of each drug class except where otherwise stated.

  • e Indicates drug added since “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents” (2004).

  • f Study did not reach the primary end point (dose response for reduction in systolic BP). Some prespecified secondary end points demonstrated effectiveness.

  • Adapted from High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):555–576.