What medication adjustments are needed for a 76-year-old patient with a history of carotid endarterectomy, fatty liver, hypertension, pre-diabetes, hepatic steatosis, Gastroesophageal Reflux Disease (GERD), cholecystectomy, and breast cancer, who recently completed radiation therapy and has hypotension?

From the Guidelines

The patient's antihypertensive medications should be adjusted to prevent low blood pressure, with consideration of decreasing the dose of her current blood pressure medications by 25-50% or temporarily discontinuing one medication if she's on multiple agents, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. Given her complex medical history, including carotid endarterectomy, fatty liver, hypertension, pre-diabetes, hepatic steatosis, GERD, and cholecystectomy, breast cancer, and recent completion of radiation therapy, it is essential to prioritize her overall health status and quality of life. The patient's report of low blood pressure during a recent office visit warrants a comprehensive medication review to minimize the risk of hypotension-related morbidity and mortality.

• The patient's blood pressure should be monitored regularly at home, with a target of maintaining systolic pressure between 120-140 mmHg and diastolic between 70-90 mmHg for a patient of her age, 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.
• Additionally, comprehensive metabolic panel, complete blood count, and liver function tests should be ordered to assess her overall health status, particularly considering her history of fatty liver and hepatic steatosis.
• The choice of antihypertensive medication should be guided by the patient's individual needs and medical history, with consideration of the major four drug classes (ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics) recommended as first-line BP-lowering medications by the 2024 ESC guidelines 1.
• Radiation therapy can cause fatigue and other side effects that may contribute to blood pressure changes, and medication needs often change following cancer treatment, highlighting the importance of regular monitoring and adjustments to her treatment plan.

From the Research

Patient's Medical History and Current Status

• The patient is a 76-year-old with a complex medical history, including carotid endarterectomy, fatty liver, hypertension, pre-diabetes, hepatic steatosis, GERD, and cholecystectomy, as well as breast cancer.
• The patient completed radiation therapy on 5/1/25 and has follow-up appointments scheduled with Dr. Close and the radiation nurse.
• The patient's blood pressure was reported to be a little low during some office visits, and they are in the clinic for medication adjustments and labs.

Radiation Therapy and Patient Experience

• Radiation therapy is a common treatment for cancer, with over half of all cancer patients receiving it at some point during their treatment 2.
• The radiation therapy process can be physically, mentally, and logistically demanding for patients, and understanding the patient experience is important for oncology nurses 2.
• The radiotherapy journey involves multiple steps, including consultation with a radiotherapist, simulation, contouring of volumes, and planning, and requires precision and time 3.

Hypertension and Hepatic Steatosis

• There is a significant association between hepatic steatosis and hypertension, both of which are linked to the metabolic syndrome 4.
• Anti-obesity medications, such as orlistat and glucagon-like peptide-1 receptor analogs, have been shown to have beneficial effects on hepatic steatosis and inflammation, but not fibrosis 5.
• Amlodipine, an anti-hypertensive drug, has been found to alleviate non-alcoholic fatty liver disease by modulating gut microbiota 6.

Potential Treatment Options

• Medications such as liraglutide, semaglutide, and orlistat may be used to treat patients with obesity and NAFLD 5.
• Amlodipine besylate and amlodipine aspartate may serve as promising therapeutic agents for treating NAFLD and hypertension by modulating gut microbiota 6.