What is the best adjustment to the blood pressure medication regimen for a new patient with hypertension, currently taking albuterol (Proventil) HFA, diazepam (Valium), diltiazem (Cardizem) LA, naproxen (Naprosyn), levothyroxine (Synthroid), tramadol (Ultram), atorvastatin (Lipitor), lisinopril (Prinivil, Zestril), and metoprolol succinate (Toprol-XL)?

From the Guidelines

The best adjustment to this patient's BP medication, given the elevated blood pressure of 178/80, is to increase the lisinopril dose from 20 mg to 40 mg daily, as recommended by the most recent guidelines 1. This approach is based on the principle of optimizing the dose of existing medications before adding new ones, especially when the current doses are not adequately controlling the patient's hypertension.

• The patient is already on a combination of lisinopril (an ACE inhibitor) and metoprolol succinate (a beta-blocker), which is an appropriate dual therapy.
• Increasing the lisinopril provides a logical first step since ACE inhibitors can often be safely titrated up before adding a third agent, according to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
• The patient should be monitored for side effects such as dizziness, hyperkalemia, or worsening renal function after this dose adjustment.
• If blood pressure remains uncontrolled after 2-4 weeks on the increased lisinopril dose, adding a thiazide diuretic like hydrochlorothiazide 12.5 mg daily would be the next appropriate step, as suggested by the guidelines 1.
• The elevated systolic pressure (178 mmHg) represents a significant cardiovascular risk factor that requires prompt attention, especially given the patient's other cardiovascular medications (diltiazem, atorvastatin, metoprolol) suggesting underlying cardiovascular disease.
• It's also important to consider the patient's current medication regimen, including albuterol HFA, diazepam, diltiazem LA, naproxen, Synthroid, tramadol, and atorvastatin, to ensure that there are no potential drug interactions that could affect blood pressure control.
• The 2018 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 also supports the use of ACE inhibitors as a first-line treatment for hypertension 1.

From the FDA Drug Label

In controlled clinical studies of patients with mild to moderate hypertension, patients were treated with lisinopril 20 mg to 80 mg daily, hydrochlorothiazide 12. 5 mg to 50 mg daily or atenolol 50 mg to 200 mg daily; and in other studies of patients with moderate to severe hypertension, patients were treated with lisinopril 20 mg to 80 mg daily or metoprolol 100 mg to 200 mg daily. Lisinopril demonstrated superior reductions of systolic and diastolic compared to hydrochlorothiazide in a population that was 75% Caucasian Lisinopril was approximately equivalent to atenolol and metoprolol in reducing diastolic blood pressure, and had somewhat greater effects on systolic blood pressure.

The patient is currently taking lisinopril (PRINIVIL, ZESTRIL) 20 mg and metoprolol succinate (TOPROL-XL) 50 mg 24 hr tablet. Given the patient's blood pressure is 178/80, which is elevated, the best adjustment to BP medication would be to increase the dose of lisinopril or add another antihypertensive agent. However, without more information about the patient's medical history and current condition, it is difficult to make a specific recommendation. Considering the patient is already taking metoprolol, increasing the dose of lisinopril to 40 mg could be a possible option, but this should be done under close medical supervision 2.

From the Research

Patient's Current Medications and Blood Pressure

• The patient is currently taking the following medications: albuterol HFA (Proventil HFA) 90 mcg/actuation inhaler, diazePAM (VALIUM) 5 mg tablet, dilTIAZem LA (Cardizem LA) 360 mg 24 hr tablet, naproxen (NAPROSYN) 500 mg tablet, Synthroid 150 mcg tablet, traMADoL (ULTRAM) 50 mg tablet, atorvastatin (LIPITOR) 40 mg tablet, lisinopriL (PRINIVIL,ZESTRIL) 20 mg tablet, metoprolol succinate (TOPROL-XL) 50 mg 24 hr tablet.
• The patient's blood pressure in the office today is 178/80 mmHg.

Adjusting Blood Pressure Medication

• According to the study 3, combination therapy with agents having complementary mechanisms of action, such as a calcium channel blocker and an angiotensin II-receptor blocker, can be a useful therapeutic option for patients with stage 2 hypertension.
• The study 4 suggests that different combinations of antihypertensive therapy, including lisinopril, losartan, or valsartan alone or in combination with hydrochlorothiazide, can be effective in reducing blood pressure and improving arterial stiffness in patients with essential hypertension.
• The study 5 recommends that more than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents, and that ACEIs and ARBs should not be used simultaneously.
• The study 6 found that rapid adjustment of antihypertensive drugs over several days can produce a durable improvement in blood pressure, and that increased use of rapid drug titration, a physician-nurse team approach, and self-BP measurement at prescribed intervals can improve BP control rates and reduce the expense and inconvenience associated with the treatment of hypertension.
• The study 7 evaluated the effectiveness of amlodipine, lisinopril, and a combination in the treatment of essential hypertension, and found that the combination of 2.5 mg amlodipine with 5 mg lisinopril produced a significant lowering of blood pressure in a higher percentage of patients than that with an individual low dose.

Potential Adjustments to the Patient's Medication Regimen

• Consider adding a calcium channel blocker, such as amlodipine, to the patient's current medication regimen, as combination therapy with a calcium channel blocker and an angiotensin II-receptor blocker can be effective in reducing blood pressure 3, 7.
• Consider adjusting the patient's current dose of lisinopriL (PRINIVIL,ZESTRIL) 20 mg tablet, as the study 4 suggests that different combinations of antihypertensive therapy, including lisinopril, can be effective in reducing blood pressure and improving arterial stiffness in patients with essential hypertension.
• Consider monitoring the patient's blood pressure closely and adjusting their medication regimen as needed, as the study 6 found that rapid adjustment of antihypertensive drugs over several days can produce a durable improvement in blood pressure.