What is the next step for a 71-year-old male with increasing hypertension who is currently taking hydrochlorothiazide (HCTZ) 25 mg and losartan (angiotensin II receptor antagonist) 100 mg?

From the Guidelines

For a 71-year-old male with increasing blood pressure despite being on hydrochlorothiazide 25 mg and losartan 100 mg, the next step would be to add a calcium channel blocker such as amlodipine 5 mg daily. This approach is based on the principle that most patients with hypertension will require two or more medications to achieve goal blood pressure, as indicated in the NHLBI guidelines 1. The addition of amlodipine, which works by relaxing blood vessel walls, complements the existing medications that work through fluid reduction (hydrochlorothiazide) and angiotensin II receptor blockade (losartan).

Starting at 5 mg of amlodipine allows for potential dose escalation to 10 mg if needed after 2-4 weeks of monitoring. It is crucial to monitor blood pressure within 2-4 weeks of starting this additional medication, along with a basic metabolic panel to monitor electrolytes and kidney function. This strategy aligns with the recommendations for managing hypertension, especially in elderly patients, where gradual blood pressure lowering is advised to avoid complications 1.

Key considerations in this management plan include:

• Monitoring for potential side effects of the added medication
• Regular follow-up to assess the effectiveness of the treatment and to make adjustments as necessary
• Emphasis on lifestyle modifications, such as diet and exercise, to support blood pressure control
• Consideration for referral to a hypertension specialist if blood pressure remains uncontrolled after the addition of the calcium channel blocker. The American Heart Association and the American Diabetes Association also recommend that patients with diabetes and hypertension should be treated with a regimen that includes either an ACE inhibitor or an ARB, and other drug classes should be added as needed to achieve blood pressure targets 1.

From the FDA Drug Label

2.2 Hypertensive Patients with Left Ventricular Hypertrophy The usual starting dose is 50 mg of losartan once daily. Hydrochlorothiazide 12. 5 mg daily should be added and/or the dose of losartan should be increased to 100 mg once daily followed by an increase in hydrochlorothiazide to 25 mg once daily based on blood pressure response [see CLINICAL STUDIES (14.2)].

The patient is already taking losartan 100 mg and hydrochlorothiazide 25 mg. The next step to increase blood pressure is not directly stated in the label. No conclusion can be drawn. 2

From the Research

Increasing Blood Pressure in a 71-Year-Old Male

The patient is currently taking hydrochlorothiazide 25 mg and losartan 100 mg. To address the increasing blood pressure, consider the following:

• The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines recommend treatment of noninstitutionalized ambulatory community-dwelling adults aged 65 years and older with an average systolic blood pressure of 130 mm Hg or higher with lifestyle measures plus antihypertensive drug to lower the blood pressure to less than 130/80 mm Hg 3.
• For elderly adults with hypertension and a high burden of comorbidities and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions about the intensity of SBP lowering and the choice of antihypertensive drugs to use for treatment 3.
• The combination therapy of losartan and hydrochlorothiazide has been shown to be effective in reducing blood pressure in hypertensive patients 4.
• Losartan has also been found to have a renoprotective effect in patients with proteinuric chronic kidney disease and hypertension, independent of its antihypertensive action 5.
• Consideration of the patient's overall health, comorbidities, and lifestyle should be taken into account when deciding on the next step in management, as outlined in the framework for improving blood pressure control in older adults 6.

Potential Next Steps

• Continue to monitor the patient's blood pressure and adjust the treatment plan as needed.
• Consider increasing the dose of losartan or adding another antihypertensive medication, such as a calcium channel blocker, to the treatment regimen.
• Encourage lifestyle modifications, such as diet and exercise, to help lower blood pressure.
• Assess the patient's kidney function and proteinuria, if applicable, to determine the best course of treatment.