What are the next steps for a 77-year-old patient on losartan (Losartan)-hydrochlorothiazide (HCTZ) 50-12.5 with mildly uncontrolled hypertension, presenting with blood pressure readings of 160/90 at times?

From the Guidelines

For a 77-year-old patient with blood pressure still elevated at 160/90 despite taking losartan-HCTZ 50-12.5 mg, the most appropriate next step is to add low-dose spironolactone to the existing treatment, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This approach is supported by the latest guidelines, which suggest that in patients with resistant hypertension, the addition of spironolactone to existing treatment should be considered.

Key Considerations

• The patient's current blood pressure is still above the recommended target, indicating the need for adjustment in their treatment regimen.
• The 2024 ESC guidelines provide the most recent and highest quality evidence for managing elevated blood pressure and hypertension, making them the primary reference for this decision.
• Adding spironolactone is a recommended strategy for managing resistant hypertension, as it can help to further reduce blood pressure and improve outcomes.
• It is essential to monitor the patient's kidney function, potassium levels, and watch for side effects like dizziness or hypotension, especially when standing, after adding spironolactone to their treatment regimen.
• Lifestyle modifications, including reducing sodium intake, maintaining physical activity as tolerated, limiting alcohol, and ensuring adequate hydration, remain crucial in managing hypertension.

Treatment Goals

• The goal for this patient should be to achieve a blood pressure target of around 130-139/70-79 mmHg, as overly aggressive targets in elderly patients can increase fall risk.
• Regular monitoring of blood pressure at home, ideally at the same time each day, is necessary to assess the effectiveness of the treatment adjustments and make further changes as needed.
• If the patient's blood pressure remains uncontrolled after the addition of spironolactone, referral to a hypertension specialist may be considered, as suggested by the American Heart Association 1.

From the FDA Drug Label

If goal blood pressure (<140/90 mmHg) was not reached, hydrochlorothiazide (12.5 mg) was added first and, if needed, the dose of losartan or atenolol was then increased to 100 mg once daily. The patient is already on losartan-hctx 50-12.5, and the blood pressure is still slightly uncontrolled.

• The next step could be to increase the dose of losartan to 100 mg once daily, as the patient is already on the lowest dose of hydrochlorothiazide (12.5 mg) 2.
• Alternatively, other antihypertensive treatments could be added to the treatment regimen to reach the goal blood pressure, such as calcium-channel blockers, alpha-blockers, or centrally acting agents, but not ACE inhibitors, angiotensin II antagonists, or beta-blockers 2.

From the Research

Treatment Options for Uncontrolled Hypertension

The patient is currently taking losartan-hctz 50-12.5 and still experiencing slightly uncontrolled blood pressure at times, with readings of 160/90. Considering the patient's age and current medication, the following options can be explored:

• Increasing the dose of losartan-hctz, as the current dose may not be sufficient to control blood pressure 3
• Adding a calcium channel blocker to the current medication, as combination therapy with an angiotensin receptor blocker (ARB) and a calcium channel blocker has been shown to be effective in reducing blood pressure 4, 5
• Switching to a different combination therapy, such as an ARB-diuretic combination, which has been shown to be effective and safe in patients with hypertension uncontrolled by ARB monotherapy 5

Combination Therapy Options

Combination therapy with two or more antihypertensive agents is often necessary to achieve adequate blood pressure control. The following combination therapy options can be considered:

• ARB-diuretic combination: losartan-hctz is an example of this combination, which has been shown to be effective in reducing blood pressure 3, 5
• ARB-calcium channel blocker combination: this combination has been shown to be effective in reducing blood pressure and can be considered as an alternative to ARB-diuretic combination 4, 5
• Triple fixed-dose drug combinations: this type of combination therapy combines a traditional renin-angiotensin system blocker, a diuretic, and a calcium channel blocker, and can be considered for patients with uncontrolled blood pressure despite dual therapy 6

Considerations for Elderly Patients

When treating elderly patients with hypertension, it is essential to consider their age, comorbidities, and potential interactions with other medications. The following considerations should be taken into account:

• Elderly patients may be more susceptible to the adverse effects of certain medications, such as diuretics, which can increase the risk of hypokalemia and other electrolyte imbalances 3
• Combination therapy with an ARB and a calcium channel blocker may be a suitable option for elderly patients, as it has been shown to be effective and safe in this population 5
• Triple fixed-dose drug combinations may not be suitable for very old and frail patients, as well as those with chronic kidney disease, due to the increased risk of adverse effects 6