What is the management approach for a patient with a history of chronic alcoholism, non-adherence to medication regimen including Losartan (angiotensin II receptor antagonist) and Amlodipine (calcium channel blocker), presenting with hypertensive crisis (Blood Pressure 200/120)?

From the Guidelines

For a chronic alcoholic in detox with severe hypertension (BP 200/120) and history of medication non-compliance with losartan and amlodipine, I recommend immediate blood pressure control with IV labetalol or nicardipine while monitoring for signs of end-organ damage, as this patient's condition is considered a hypertensive urgency rather than an emergency, given the lack of evidence of new or worsening target organ damage 1.

Key Considerations

• The patient's blood pressure is severely elevated, but there is no indication of acute target organ damage, which suggests a hypertensive urgency rather than an emergency 1.
• The patient's history of non-compliance with medication is a significant concern, and strategies to improve adherence should be implemented, such as once-daily dosing, simplifying the regimen, and providing adherence feedback 1.
• The patient requires close monitoring for signs of end-organ damage, including stroke, myocardial infarction, and renal failure.
• Long-term management should include addiction treatment, medication adherence counseling, and consideration of extended-release formulations or combination pills to simplify the regimen.

Management Approach

• Restart oral antihypertensives with consideration for once-daily dosing to improve compliance, beginning with amlodipine 10mg daily and losartan 50-100mg daily, with potential addition of a thiazide diuretic like chlorthalidone 12.5-25mg daily if needed.
• Address alcohol withdrawal with appropriate benzodiazepine protocol.
• Consider the use of single pill combinations, home BP monitoring, and reminder packaging of medications to improve medication adherence 1.
• A multidisciplinary healthcare team approach, including pharmacists, can help improve monitoring for adherence and provide empowerment-based counseling for self-management 1.

From the FDA Drug Label

Losartan is indicated for the treatment of hypertension in adults and pediatric patients 6 years of age and older, to lower blood pressure. Lowering blood pressure lowers the risk of fatal and nonfatal cardiovascular (CV) events, primarily strokes and myocardial infarction Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits

The patient has a blood pressure of 200/120, which is significantly elevated. Losartan and Amlodipine are both indicated for the treatment of hypertension.

• The patient is not compliant with their current medication regimen, which includes Losartan and Amlodipine.
• Given the patient's history of non-compliance, it is essential to consider alternative treatment options or strategies to improve adherence.
• However, based on the provided information, it is unclear what changes should be made to the patient's current treatment regimen.
• The FDA drug label does not provide direct guidance on how to manage a patient with a history of non-compliance and severely elevated blood pressure.
• Therefore, a conservative clinical decision would be to consult with a healthcare professional to determine the best course of action for this patient. 2, 2, 3

From the Research

Patient Assessment

• The patient is a chronic alcoholic undergoing detoxification with a history of non-compliance with medications, including losartan and amlodipine.
• The patient's blood pressure is 200/120 mmHg, which is severely elevated.
• According to 4, hypertensive emergency occurs when blood pressure is severely elevated (higher than 180 mmHg systolic or higher than 120 mmHg diastolic) and acute organ damage is present.

Treatment Approach

• Since the patient does not have symptoms of acute target organ injury, the condition can be classified as severe asymptomatic hypertension, as defined in 5 and 6.
• Management of severe asymptomatic hypertension starts with long-acting antihypertensive drugs, typically a combination of a renin-angiotensin system inhibitor, a thiazide diuretic, and/or a calcium channel blocker, as stated in 4.
• The goal is to gradually reduce blood pressure over several days to weeks, avoiding aggressive lowering of blood pressure, as recommended in 5 and 6.
• Intravenous medications, such as clevidipine, may be considered in certain situations, as discussed in 7, but are not typically used for asymptomatic severe hypertension.

Monitoring and Follow-up

• Close monitoring of the patient's blood pressure and adjustment of the treatment regimen as needed are crucial, as emphasized in 4 and 6.
• Regular follow-up appointments are necessary to assess the patient's response to treatment and make adjustments to achieve the desired blood pressure goals, as stated in 6.