Alternating monotherapy is the preferred treatment

The choice of initial therapy of hypertensive patients may be critical in the long-term efforts to reduce premature cardiovascular morbidity and mortality. In the 1984 report of the third Joint National Committee (JNC), significant changes in the usual approach to initial therapy were suggested, including a more conservative approach toward the institution of drug therapy, more liberal use of nondrug therapies and broader choices for the initial drug. I support these changes and believe that even a greater number of choices for initial therapy should be considered. I am increasingly concerned about the hazards of diuretic therapy and believe that for most patients, an adrenergic inhibitor is preferable for first drug. Rather than limit the type of adrenergic inhibitor to a beta blocker as suggested in the JNC report, either an alpha blocker or a centrally acting drug may be preferable. In the near future, calcium antagonists will likely also become logical choices.