What is the management approach for a 72-year-old male with a history of hypertension (HTN) taking amlodipine (10 mg) and torsemide, with allergies to angiotensin-converting enzyme inhibitors (ACE inhibitors, prils), presenting with stage 2 hypertension (systolic blood pressure 145-155 mmHg) and hypotension (diastolic blood pressure 60's-70's mmHg)?

From the Guidelines

For this 72-year-old male with hypertension whose blood pressure remains elevated at 145-155/60-70 mmHg despite taking amlodipine 10 mg daily, I recommend adding losartan 50 mg once daily to his regimen. Given his allergy to ACE inhibitors ("prils") and current use of torsemide (a loop diuretic), an angiotensin receptor blocker (ARB) like losartan would be an appropriate addition, as suggested by 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. Start with 50 mg daily and monitor blood pressure over 2-4 weeks, with a target of less than 130/80 mmHg for his age group. If needed, the losartan dose can be increased to 100 mg daily. This combination works well because amlodipine blocks calcium channels to relax blood vessels while losartan blocks angiotensin II receptors, providing complementary mechanisms to lower blood pressure. Additionally, losartan offers renal protection benefits. Monitor potassium and renal function within 1-2 weeks of starting therapy, especially since he's already on torsemide.

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

• The importance of achieving a target blood pressure of less than 130/80 mmHg, as recommended by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.
• The need to monitor for potential adverse effects of losartan, such as hyperkalemia, particularly in patients with chronic kidney disease or those taking potassium-sparing diuretics.
• The consideration of adding a thiazide diuretic, such as chlorthalidone, as a third agent if blood pressure remains uncontrolled after maximizing losartan, as suggested by the treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention 1.

Overall, the addition of losartan to this patient's regimen is a reasonable and evidence-based approach to managing his hypertension, with the goal of reducing his risk of cardiovascular morbidity and mortality, and improving his quality of life.

From the FDA Drug Label

1.2 Hypertension Torsemide tablets are indicated for the treatment of hypertension, to lower blood pressure. Many patients will require more than one drug to achieve blood pressure goals Torsemide tablets can be used alone or in combination with other antihypertensive agents.

The patient is already taking amlodipine 10 mg and torsemide for hypertension, but the blood pressure readings are still 145-155 sbp over 60's to 70's, indicating that the current treatment may not be sufficient to achieve optimal blood pressure control.

• The patient may require adjustment of current medication or addition of another antihypertensive agent to achieve blood pressure goals.
• It is also important to consider lifestyle modifications, such as limited sodium intake, exercise, and smoking cessation, as part of comprehensive cardiovascular risk management 2.

From the Research

Patient Profile

• 72-year-old male with a history of hypertension
• Currently taking amlodipine 10 mg
• Allergic to prils (angiotensin-converting enzyme inhibitors)
• Taking torsemide (a loop diuretic)
• Blood pressure readings: 145-155 mmHg systolic, 60's to 70's mmHg diastolic

Treatment Considerations

• According to 3, more than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents
• The patient is already taking a calcium channel blocker (amlodipine) and a loop diuretic (torsemide)
• Considering the patient's allergy to prils, alternative treatment options may include adding a thiazide diuretic or another calcium channel blocker
• 4 suggests that adding a new medication may be associated with less intensification sustainability but slightly larger reductions in systolic blood pressure

Blood Pressure Management

• The patient's blood pressure readings are above the recommended target range
• 5 suggests that reducing blood pressure to levels below those currently advocated for cardiovascular risk reduction may not provide readily identifiable benefits in African American patients with hypertensive nephrosclerosis
• However, 6 found that adding a calcium antagonist (such as amlodipine) to a renin-angiotensin system inhibitor resulted in greater improvements in augmentation index and urinary protein excretion compared to adding a diuretic
• 7 found that ramipril (an angiotensin-converting enzyme inhibitor) was more effective than amlodipine in retarding renal disease progression in patients with hypertensive renal disease and proteinuria, but this may not be applicable to the patient due to their allergy to prils

Potential Next Steps

• Consider adding a thiazide diuretic or another calcium channel blocker to the patient's treatment regimen
• Monitor the patient's blood pressure and adjust the treatment plan as needed to achieve optimal blood pressure control
• Regularly assess the patient's kidney function and proteinuria to determine the effectiveness of the treatment plan