From the Guidelines
For a 67-year-old female with recently elevated blood pressure on multiple medications, the next best adjustment would be to increase amlodipine from 5 mg to 10 mg daily, as this modification targets the elevated blood pressure directly by enhancing the calcium channel blocking effect, which promotes vasodilation and reduces peripheral resistance 1. Amlodipine is a preferred agent in older adults and works well with the patient's existing losartan 100 mg, which is already at maximum dose. The atenolol 50 mg should be maintained as it complements the antihypertensive regimen through a different mechanism.
According to the 2007 guidelines for the management of arterial hypertension, initial doses and subsequent dose titration should be more gradual because of a greater chance of undesirable effects, especially in very old and frail subjects 1. However, in this case, increasing the amlodipine dose is a reasonable step to achieve better blood pressure control. The BP goal is the same as in younger patients, i.e., 140/90 mmHg or below, if tolerated 1.
No changes are needed to the non-blood pressure medications (vitamin D, ezetimibe, hydroxyzine, magnesium, melatonin, and psyllium). After increasing amlodipine, blood pressure should be rechecked in 2-4 weeks to assess response, and electrolytes and renal function should be monitored, particularly given the combination of losartan and atenolol which can affect potassium levels and kidney function. It is also important to measure blood pressure in the erect posture to assess the risk of postural hypotension 1.
Key considerations in this patient's management include:
- Monitoring blood pressure regularly to assess the response to the increased amlodipine dose
- Adjusting the dose gradually to minimize the risk of undesirable effects
- Maintaining the existing losartan and atenolol doses to ensure a comprehensive antihypertensive regimen
- Continuously monitoring electrolytes and renal function to prevent potential adverse effects 1.
From the FDA Drug Label
2 DOSAGE & ADMINISTRATION
2.1 Adults The usual initial antihypertensive oral dose of Amlodipine besylate tablets is 5 mg once daily, and the maximum dose is 10 mg once daily. Adjust dosage according to blood pressure goals. In general, wait 7 to 14 days between titration steps. Titrate more rapidly, however, if clinically warranted, provided the patient is assessed frequently
The next best dose adjustment for amLODIPine (NORVASC) could be to increase the dose to 10 mg once daily, as the patient is currently on the minimum dose of 5 mg and has recently elevated BP. However, this decision should be made with caution and careful monitoring of the patient's blood pressure, as the patient is also on atenoloL (TENORMIN) and losartan (COZAAR), which are also antihypertensive medications. It is also important to consider the potential interactions between these medications and adjust the doses accordingly 2.
- Consider increasing amLODIPine (NORVASC) to 10 mg once daily
- Monitor patient's BP closely
- Consider potential interactions with other antihypertensive medications, such as atenoloL (TENORMIN) and losartan (COZAAR).
From the Research
Medication Analysis
The patient is currently taking the following medications:
- amLODIPine (NORVASC) 5 mg tablet
- atenoloL (TENORMIN) 50 mg tablet
- cholecalciferol (VITAMIN D-3) 50 mcg (2,000 unit) capsule
- ezetimibe (ZETIA) 10 mg tablet
- hydrOXYzine pamoate (VISTARIL) 25 mg capsule
- losartan (COZAAR) 100 mg tablet
- MAGNESIUM GLYCINATE, BULK, MISC
- MELATONIN ORAL
- psyllium seed, with sugar, (FIBER ORAL)
Potential Adjustments
Based on the provided studies, potential adjustments to the patient's medication regimen could include:
- Increasing the dose of amLODIPine (NORVASC) to 10 mg, as seen in the study 3, which demonstrated the efficacy of perindopril/indapamide/amlodipine single-pill combination in patients with uncontrolled essential hypertension.
- Considering alternative antihypertensive medications, such as losartan, which was shown to be effective in reducing blood pressure variability in the study 4.
- Monitoring the patient's blood pressure and adjusting the medication regimen as needed to achieve optimal blood pressure control, as recommended in the study 5.
- Combining losartan with other antihypertensive medications, such as hydrochlorothiazide, to achieve better blood pressure control, as seen in the study 6.
- Using a combination of antihypertensive medications, including amlodipine, to reduce blood pressure and arterial stiffness, as demonstrated in the study 7.
Key Considerations
- The patient's current medication regimen includes both amLODIPine and losartan, which may be contributing to their elevated blood pressure.
- The study 4 suggests that amlodipine may be more effective in reducing blood pressure variability than losartan.
- The study 7 demonstrates that different combinations of antihypertensive medications can be effective in reducing blood pressure and arterial stiffness.
- The patient's medication regimen should be carefully monitored and adjusted as needed to achieve optimal blood pressure control and minimize potential side effects.