Obesity prevalence is increasing. Obesity frequently coexists with-and can cause or worsen-arterial hypertension. However, no current guidelines provide specific recommendations. Antihypertensive drug treatment is indicated in most obese hypertensive patients, leading to the obvious question: what is the best drug treatment for this population? Some antihypertensive agents may have unwanted effects on the metabolic and hemodynamic abnormalities linking obesity and hypertension. Without adequate studies, recommendations for or against each class of antihypertensive agents are based on subjective criteria and pathophysiologic assumptions. Diuretics and beta-blockers have unwanted effects, whereas calcium antagonists are metabolically neutral, and angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers may increase insulin sensitivity. The renin-angiotensin system in adipose tissue has been implicated in arterial hypertension, and sodium retention is central to obesity-related hypertension. Therefore, an ACE inhibitor or diuretic should be considered as first-line antihypertensive drug therapy in obesity-hypertension.