TABLE 9.

Antihypertensive Drugs for Outpatient Management of Hypertension in Children 1–17 Years Old*

ClassDrugDoseDosing IntervalEvidenceFDA Labeling§Comments‖Verbar;
ACE inhibitorBenazeprilInitial: 0.2 mg/kg per d up to 10 mg/dqdRCTYes
  1. All ACE inhibitors are contraindicated in pregnancy; females of childbearing age should use reliable contraception.

  2. 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.

  4. Benazepril, enalapril, and lisinopril labels contain information on the preparation of a suspension; captopril may also be compounded into a suspension.

  5. FDA approval for ACE inhibitors with pediatric labeling is limited to children ≥6 years of age and to children with creatinine clearance ≥30 ml/min per 1.73m2.

Maximum: 0.6 mg/kg per d up to 40 mg/d
CaptoprilInitial: 0.3–0.5 mg/kg/dosetidRCT, CSNo
Maximum: 6 mg/kg per d
EnalaprilInitial: 0.08 mg/kg per d up to 5 mg/dqd-bidRCTYes
Maximum: 0.6 mg/kg per d up to 40 mg/d
FosinoprilChildren >50 kg:qdRCTYes
Initial: 5–10 mg/d
Maximum: 40 mg/d
LisinoprilInitial: 0.07 mg/kg per d up to 5 mg/dqdRCTYes
Maximum: 0.6 mg/kg per d up to 40 mg/d
QuinaprilInitial: 5–10 mg/dqdRCT, EONo
Maximum: 80 mg/d
Angiotensin-receptor blockerIrbesartan6–12 years: 75–150 mg/dqdCSYes
  1. All ARBs are contraindicated in pregnancy; females of childbearing age should use reliable contraception.

  2. Check serum potassium, creatinine periodically to monitor for hyperkalemia and azotemia.

  3. Losartan label contains information on the preparation of a suspension.

  4. FDA approval for ARBs is limited to children ≥6 years of age and to children with creatinine clearance ≥30 ml/min per 1.73m2.

≥13 years: 150–300 mg/d
LosartanInitial: 0.7 mg/kg per d up to 50 mg/dqdRCTYes
Maximum: 1.4 mg/kg per d up to 100 mg/d
α- and β-BlockerLabetalolInitial: 1–3 mg/kg per dbidCS, EONo
  1. Asthma and overt heart failure are contraindications.

  2. Heart rate is dose-limiting.

  3. May impair athletic performance.

  4. Should not be used in insulin-dependent diabetics.

Maximum: 10–12 mg/kg per d up to 1200 mg/d
β-BlockerAtenololInitial: 0.5–1 mg/kg per dqd-bidCSNo
  1. Noncardioselective agents (propranolol) are contraindicated in asthma and heart failure.

  2. Heart rate is dose-limiting.

  3. May impair athletic performance.

  4. Should not be used in insulin-dependent diabetics.

  5. A sustained-release formulation of propranolol is available that is dosed once-daily.

Maximum: 2 mg/kg per d up to 100 mg/d
Bisoprolol/HCTZInitial: 2.5/6.25 mg/dqdRCTNo
Maximum: 10/6.25 mg/d
MetoprololInitial: 1–2 mg/kg per dbidCSNo
Maximum: 6 mg/kg per d up to 200 mg/d
PropranololInitial: 1–2 mg/kg per dbid-tidRCT, EOYes
Maximum: 4 mg/kg per d up to 640 mg/d
Calcium channel blockerAmlodipineChildren 6–17 years: 2.5–5 mg once dailyqdRCTYes
  1. Amlodipine and isradipine can be compounded into stable extemporaneous suspensions.

  2. Felodipine and extended-release nifedipine tablets must be swallowed whole.

  3. Isradipine is available in both immediate-release and sustained-release formulations; sustained-release form is dosed qd or bid.

  4. May cause tachycardia.

FelodipineInitial: 2.5 mg/dqdRCT, EONo
Maximum: 10 mg/d
IsradipineInitial: 0.15–0.2 mg/kg per dtid-qidCS, EONo
Maximum: 0.8 mg/kg per d up to 20 mg/d
Extended-release nifedipineInitial: 0.25–0.5 mg/kg per dqd-bidCS, EONo
Maximum: 3 mg/kg per d up to 120 mg/d
Central α-agonistClonidineChildren ≥12 years:bidEOYes
  1. May cause dry mouth and/or sedation.

  2. Transdermal preparation also available.

  3. Sudden cessation of therapy can lead to severe rebound hypertension.

Initial: 0.2 mg/d
Maximum: 2.4 mg/d
DiureticHCTZInitial: 1 mg/kg per dqdEOYes
  1. All patients treated with diuretics should have electrolytes monitored shortly after initiating therapy and periodically thereafter.

  2. Useful as add-on therapy in patients being treated with drugs from other drug classes.

  3. Potassium-sparing diuretics (spironolactone, triamterene, amiloride) may cause severe hyperkalemia, especially if given with ACE inhibitor or ARB.

  4. 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.

  5. Chlorthalidone may precipitate azotemia in patients with renal diseases and should be used with caution in those with severe renal impairment.

Maximum: 3 mg/kg per d up to 50 mg/d
ChlorthalidoneInitial: 0.3 mg/kg per dqdEONo
Maximum: 2 mg/kg per d up to 50 mg/d
FurosemideInitial: 0.5–2.0 mg/kg per doseqd-bidEONo
Maximum: 6 mg/kg per d
SpironolactoneInitial: 1 mg/kg per dqd-bidEONo
Maximum: 3.3 mg/kg per d up to 100 mg/d
TriamtereneInitial: 1–2 mg/kg per dbidEONo
Maximum: 3–4 mg/kg per d up to 300 mg/d
AmilorideInitial: 0.4–0.625 mg/kg per dqdEONo
Maximum: 20 mg/d
Peripheral α-antagonistDoxazosinInitial: 1 mg/dqdEONoMay cause hypotension and syncope, especially after first dose.
Maximum: 4 mg/d
PrazosinInitial: 0.05–0.1 mg/kg per dtidEONo
Maximum: 0.5 mg/kg per d
TerazosinInitial: 1 mg/dqdEONo
Maximum: 20 mg/d
VasodilatorHydralazineInitial: 0.75 mg/kg per dqidEOYes
  1. Tachycardia and fluid retention are common side effects.

  2. Hydralazine can cause a lupus-like syndrome in slow acetylators.

  3. Prolonged use of minoxidil can cause hypertrichosis.

  4. Minoxidil is usually reserved for patients with hypertension resistant to multiple drugs.

Maximum: 7.5 mg/kg per d up to 200 mg/d
MinoxidilChildren <12 years:qd-tidCS, EOYes
Initial: 0.2 mg/kg per d
Maximum: 50 mg/d Children ≥12 years:
Initial: 5 mg/d
Maximum: 100 mg/d
  • FDA indicates Federal Drug Administration; ARB indicates angiotensin-receptor blocker; bid, twice daily; HCTZ, hydrochlorothiazide; qd, once daily; qid, four times daily; tid, three times daily.

  • * Includes drugs with prior pediatric experience or recently completed clinical trials.

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

  • Level of evidence upon which dosing recommendations are based. CS indicates case series; EO, expert opinion; RCT, randomized controlled trial.

  • § FDA-approved pediatric labeling information is available. Recommended doses for agents with FDA-approved pediatric labels 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.

  • ‖Verbar; Comments apply to all members of each drug class except where otherwise stated.