What is the appropriate management for a patient with hypotension, currently taking losartan (100 mg daily), amlodipine (10 mg daily), and hydralazine (50 mg twice daily)?

From the Guidelines

Discontinuing hydralazine and reassessing blood pressure is appropriate for this patient with systolic BP in the lower teens. The patient is already on maximum doses of losartan 100 mg daily and amlodipine 10 mg daily, and the addition of hydralazine 50 mg twice daily has likely contributed to excessive blood pressure lowering, as seen in the context of managing hypertensive emergencies 1. When systolic blood pressure drops too low (below 120 mmHg and especially below 110 mmHg), patients may experience symptoms of hypotension such as dizziness, lightheadedness, fatigue, or syncope. Key considerations for managing this patient's blood pressure include:

• Monitoring blood pressure regularly, ideally within 1-2 weeks after discontinuing hydralazine
• Being prepared to adjust the remaining medications if blood pressure remains too low or rises excessively after discontinuation
• Maintaining blood pressure in a safe range (typically 120-130/70-80 mmHg for most adults) while minimizing side effects from medication, as guided by the principles outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The goal is to balance the control of blood pressure with the potential risks of hypotension, always prioritizing the patient's morbidity, mortality, and quality of life.

From the FDA Drug Label

The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure [see CLINICAL STUDIES (14.1)]. A starting dose of 25 mg is recommended for patients with possible intravascular depletion (e.g., on diuretic therapy).

The patient is already on losartan 100 mg daily, amlodipine 10 mg daily, and hydralazine 50 mg twice daily. To answer the question of whether to discontinue hydralazine and reassess BP, we must consider the current BP is in the lower teens for systolic.

• The losartan dose is already at the maximum recommended dose.
• There is no direct information in the provided drug labels that supports discontinuing hydralazine based on the patient's current BP.
• However, given the patient's BP is low, it may be prudent to consider reducing or discontinuing one of the antihypertensive medications to avoid potential hypotension.
• Considering the patient is on multiple antihypertensive agents, discontinuing hydralazine and reassessing BP may be a reasonable approach to avoid potential hypotension, but this decision should be made with caution and close monitoring of the patient's BP. 2 2

From the Research

Discontinuation of Hydralazine and Reassessment of BP

• The decision to discontinue hydralazine and reassess blood pressure (BP) is based on the patient's current BP readings, which are in the lower teens for systolic, and their current medication regimen, including losartan 100 mg daily, amlodipine 10 mg daily, and hydralazine 50 mg twice daily 3.
• According to a study published in 2008, modern antihypertensive drugs, including hydralazine, can be abruptly and safely withdrawn in most patients, but a gradual dose taper may be necessary in certain cases 3.
• Another study from 1982 found that hydralazine can be administered twice daily, and there is no need to administer it more than twice daily 4.

Alternative Treatment Options

• A 2019 study compared the efficacy of different antihypertensive drug combinations, including losartan and amlodipine, and found that they were equally effective in reducing systolic and diastolic blood pressure and improving arterial stiffness in patients with essential hypertension 5.
• A 2020 study compared the ability of losartan and amlodipine to lower blood pressure variability and systolic blood pressure in essential hypertensive patients, and found that amlodipine may be better at lowering blood pressure variability 6.
• A 2007 study compared the effectiveness of add-on low-dose diuretics in combination therapy for hypertension, including losartan/hydrochlorothiazide vs. candesartan/amlodipine, and found that the losartan/hydrochlorothiazide combination was effective and safe 7.

Considerations for Discontinuation of Hydralazine

• When discontinuing hydralazine, it is essential to monitor the patient's BP closely to ensure that it remains within a safe range 3.
• The patient's medication regimen may need to be adjusted to maintain optimal BP control, and alternative treatment options, such as those mentioned above, may be considered 5, 6, 7.