What is the next best antihypertensive medication for a 50-year-old male with uncontrolled hypertension (HTN) and a blood pressure of 150/100 mmHg, who cannot tolerate lisinopril (an angiotensin-converting enzyme inhibitor) due to a persistent cough?

From the Guidelines

Losartan is the most appropriate next medication choice for this 50-year-old male with hypertension who cannot tolerate lisinopril due to cough. Angiotensin II receptor blockers (ARBs) like losartan are typically recommended when ACE inhibitors cause cough, as they provide similar antihypertensive benefits without the cough side effect 1. A typical starting dose would be losartan 50 mg once daily, which can be increased to 100 mg daily if blood pressure remains elevated after 2-4 weeks. The cough associated with ACE inhibitors like lisinopril occurs because these medications increase bradykinin levels in the lungs, whereas ARBs do not affect bradykinin metabolism. For a patient with a blood pressure of 150/100 mmHg, achieving control below 130/80 mmHg would be the goal.

Some key points to consider in the management of this patient's hypertension include:

• Lifestyle modifications, such as reduced sodium intake, regular exercise, and weight management, should continue alongside medication therapy 1.
• The patient should be advised to take the medication consistently and monitor blood pressure at home if possible.
• Follow-up within 4 weeks to assess efficacy and tolerability is recommended.
• If blood pressure remains uncontrolled, consideration of adding another antihypertensive agent, such as a calcium channel blocker or a diuretic, may be necessary, as most people with high blood pressure will require at least two blood pressure lowering drugs to achieve the recommended goals 1.

Overall, the goal is to achieve optimal blood pressure control while minimizing side effects and improving the patient's quality of life.

From the FDA Drug Label

The incidence of cough associated with losartan therapy, in a population that all had cough associated with ACE-inhibitor therapy, is similar to that associated with hydrochlorothiazide or placebo therapy Cases of cough, including positive re-challenges, have been reported with the use of losartan in postmarketing experience. Two prospective, parallel-group, double-blind, randomized, controlled trials were conducted to assess the effects of losartan on the incidence of cough in hypertensive patients who had experienced cough while receiving ACE-inhibitor therapy The incidence of cough is shown in Table 1 below Table 1 Study 1 HCTZ Losartan Lisinopril Cough 25% 17% 69% Study 2 Placebo Losartan Lisinopril Cough 35% 29% 62%

Losartan can be considered as an alternative for a 50-year-old male with hypertension who cannot tolerate lisinopril due to cough, as the incidence of cough associated with losartan therapy is similar to that associated with hydrochlorothiazide or placebo therapy 2.

• The studies demonstrate that losartan has a lower incidence of cough compared to lisinopril.
• Losartan was effective in reducing blood pressure regardless of race, although the effect was somewhat less in Black patients 2.
• It is essential to monitor the patient's blood pressure and adjust the dosage as needed to achieve the desired therapeutic effect.

From the Research

Alternative Medications for Hypertension

• If a 50-year-old male patient with hypertension (150/100 mmHg) cannot tolerate lisinopril due to cough, alternative medications can be considered.
• Losartan, an angiotensin receptor blocker (ARB), may be a suitable option as it has been shown to be effective in reducing blood pressure 3.
• However, combination therapy with a calcium channel blocker and an ACE inhibitor or ARB may be more effective in achieving normotensive blood pressures 4, 5, 6.

Combination Therapy

• Combination therapy with a calcium channel blocker and an ACE inhibitor, such as ramipril and amlodipine, has been shown to be effective and well-tolerated 5, 6.
• This combination may be particularly beneficial for patients with cardiovascular risk factors or target organ damage 6.
• The use of fixed combinations, such as perindopril and amlodipine, can increase compliance with treatment and improve blood pressure control 6.

Other Options

• Beta blockers, such as metoprolol, may also be considered as an alternative or addition to other medications 3, 7.
• Thiazide diuretics may be used in combination with other medications, particularly in patients with heart failure or chronic kidney disease 7.
• The choice of medication should be individualized based on the patient's specific needs and medical history 7.