From the Guidelines
The patient's symptoms of elevated blood pressure and orthostatic dizziness require prompt management, and I recommend temporarily reducing the Lasix (furosemide) dose to 10mg daily and maintaining the carvedilol at 6.25mg twice daily while increasing fluid intake and monitoring blood pressure at home, as suggested by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The orthostatic symptoms suggest volume depletion from the diuretic, which can paradoxically worsen blood pressure control. Laboratory evaluation should be performed to check electrolytes, kidney function, and complete blood count. Once orthostatic symptoms resolve, blood pressure medication can be adjusted as needed, potentially increasing carvedilol to 12.5mg twice daily if hypertension persists, considering the patient's response and tolerance to the medication, as recommended by the American Heart Association Council for High Blood Pressure Research 1. The patient should be instructed to rise slowly from sitting or lying positions and report worsening symptoms. This approach addresses the competing issues of hypertension and orthostatic hypotension by first ensuring adequate volume status before intensifying antihypertensive therapy, which is crucial in managing patients with elevated blood pressure and orthostatic dizziness, as highlighted in the 2021 and 2022 standards of medical care in diabetes 1. Follow-up within 1-2 weeks is essential to reassess symptoms and medication efficacy, allowing for timely adjustments to the treatment plan and ensuring optimal management of the patient's condition. Additionally, non-pharmacologic measures such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, and using compressive garments over the legs and abdomen may be beneficial in managing orthostatic hypotension, as suggested by the 2018 standards of medical care in diabetes 1. Midodrine and droxidopa, approved by the FDA for the treatment of orthostatic hypotension, may also be considered if symptoms persist despite these measures, as recommended by the European Heart Journal 1.
From the FDA Drug Label
The usual initial dose of Furosemide tablets for hypertension is 80 mg, usually divided into 40 mg twice a day. Dosage should then be adjusted according to response If response is not satisfactory, add other antihypertensive agents. Changes in blood pressure must be carefully monitored when Furosemide tablets are used with other antihypertensive drugs, especially during initial therapy.
The patient is currently on Lasix (furosemide) 20mg qd and carvedilol 6.25 mg bid. The patient's dose of furosemide is lower than the recommended initial dose for hypertension.
- The dose of furosemide may need to be adjusted to achieve the desired therapeutic response.
- The patient's blood pressure should be carefully monitored when adjusting the dose of furosemide or adding other antihypertensive agents.
- The patient's dizziness when standing may be a sign of orthostatic hypotension, which can be exacerbated by diuretics like furosemide.
- The patient's carvedilol dose may need to be adjusted to prevent excessive drop in blood pressure.
- The patient should be closely monitored for signs of dehydration, electrolyte imbalances, and renal insufficiency when taking furosemide 2.
- Furosemide tablets combined with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers may lead to severe hypotension and deterioration in renal function, including renal failure 2.
From the Research
Management and Treatment of Orthostatic Hypotension
The patient's symptoms of dizziness when standing, despite being on carvedilol 6.25 mg bid and lasix 20mg qd, suggest orthostatic hypotension (OH) 3, 4. The treatment goals for OH are to reduce symptoms and improve quality of life.
Nonpharmacologic Strategies
Nonpharmacologic strategies for managing OH include:
- Dietary modifications
- Compression garments
- Physical maneuvers
- Avoiding environments that exacerbate symptoms 4
- Water bolus treatment and physical countermaneuvers to improve orthostatic defenses during periods of increased orthostatic stress 3
Pharmacologic Strategies
Pharmacologic strategies for managing OH include:
- Midodrine and droxidopa as first-line medications 4
- Fludrocortisone, although it has concerning long-term effects 4
- Pressor agents, such as midodrine or droxidopa, supplemented with procedures to improve orthostatic defenses 3
Considerations for Hypertension Management
When managing hypertension in patients with OH, it is essential to consider the risk of hypotension and hypotension-related events, particularly in older adults 5. The treatment of asymptomatic elevated inpatient BP is less clear, and recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient BP 6.
Adjusting Medications
The patient's current medications, carvedilol and lasix, may be contributing to the OH. Adjusting these medications or adding new medications to manage OH should be done with caution, considering the patient's individual needs and medical history 4, 7.
Monitoring and Follow-up
Regular monitoring of the patient's blood pressure and symptoms is crucial to adjust the treatment plan as needed and minimize the risk of hypotension and hypotension-related events 3, 4, 7.