From the Guidelines
Aurelio should prioritize consolidating his medications to a single pharmacy to improve medication management and reduce confusion, as this will help minimize the risk of medication errors, missed doses, and potential drug interactions, which is crucial for maintaining his target blood pressure and preventing future complications, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. To implement this change, Aurelio should choose his preferred pharmacy, inform his healthcare providers to send all new prescriptions there, and ask the chosen pharmacy to transfer his existing prescriptions. He should also create a complete medication list to share with his providers and pharmacy. Given his complex medical history, including ESRD on hemodialysis, resistant hypertension, heart failure, CAD, GERD, and type 2 diabetes, and recent hospitalization for hypertensive urgency, proper medication management is vital. The current antihypertensive regimen, which includes carvedilol 25 mg BID, lisinopril 20 mg BID, amlodipine 10 mg daily, doxazosin 2 mg daily, and hydralazine 25 mg TID, plus furosemide 80 mg BID, should be reviewed and optimized according to the latest guidelines, considering the patient's response to treatment and potential side effects, as suggested by the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1. Additionally, the patient's blood pressure goal should be individualized, taking into account his age, comorbidities, and tolerance to treatment, with a target systolic blood pressure of <130 mmHg, if tolerated, but not <120 mmHg, as recommended by the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1. It is also important to consider the patient's renal function and potential interactions between his medications, as well as the need for regular monitoring of his blood pressure, renal function, and electrolyte levels, as suggested by the treatment of hypertension in the prevention and management of ischemic heart disease guidelines 1.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION Edema Therapy should be individualized according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response. The dose of Furosemide tablets may be carefully titrated up to 600 mg/day in patients with clinically severe edematous states. Hypertension Therapy should be individualized according to the patient's response to gain maximal therapeutic response and to determine the minimal dose needed to maintain the therapeutic response. The usual initial dose of Furosemide tablets for hypertension is 80 mg, usually divided into 40 mg twice a day.
The patient is currently taking furosemide 80 mg BID daily, which is within the recommended dosage range for hypertension. However, the patient's dose may need to be adjusted based on their individual response to the medication.
- The patient's blood pressure is currently controlled, with readings in the 130's-160's/60-80's range, and occasionally in the 170's.
- The patient is also taking other antihypertensive medications, including carvedilol, lisinopril, amlodipine, doxazosin, and hydralazine.
- The patient's renal function should be closely monitored, as they have a history of ESRD and are on hemodialysis.
- The patient's electrolyte levels should also be monitored, as furosemide can cause electrolyte imbalances 2.
- Additionally, the patient's kidney function should be monitored when taking furosemide with other medications, such as NSAIDs or ACE inhibitors, as this can increase the risk of kidney damage 2 3.
From the Research
Patient Profile
- Aurelio is a 70-year-old male with a history of ESRD on HD, resistant HTN, HFpEF, CAD, GERD, and T2DM.
- He was admitted to the hospital for hypertensive urgency and postussive emesis/hematemesis from 4/21-4/24/25.
- Since hospital discharge, the patient reports feeling much better, with improved cough and no dizziness, lightheadedness, chest pain, or shortness of breath.
Medication Regimen
- The patient is taking multiple medications for his conditions, including:
- Carvedilol 25 mg PO BID daily
- Lisinopril 20 mg BID daily
- Amlodipine 10 mg PO daily
- Doxazosin 2 mg PO daily
- Hydralazine 25 mg PO TID
- Furosemide 80 mg BID daily
- The patient's BP goal is between 140-160 mmHg, and he reports taking all his medications as indicated.
Medication Adherence
- The patient notes that he would like to get all his medications from one pharmacy to have better control of his medications, as he is currently getting medications from 3 different places, causing confusion 4, 5.
- Studies have shown that simplification of medication regimens, electronic health tools, patient education, and behavioral counseling can improve medication adherence 4, 6.
Blood Pressure Management
- The patient's blood pressures are controlled for the most part, with readings in the 130's-160's/60-80's, and occasionally in the 170's 7.
- The patient's current antihypertensive medication regimen includes a combination of medications, which has been shown to be effective in reducing blood pressure and improving arterial stiffness 8.
Hemodialysis
- The patient receives hemodialysis on Tuesdays, Thursdays, and Saturdays, with his last session being yesterday, where 3 L of fluid were removed, and blood pressures were stable.
- The patient has another hemodialysis session scheduled for tomorrow at 0650.