From the Guidelines
This patient requires immediate blood pressure management due to severe hypertension, and I recommend increasing the lisinopril to 40mg daily and amlodipine to 10mg daily, which are both maximum doses, as well as adding a third agent such as chlorthalidone 25mg daily. The patient's current blood pressure of 200/100 mmHg puts them at high risk for end-organ damage, including stroke, heart attack, and kidney injury 1. According to the 2017 American College of Cardiology/American Heart Association hypertension guideline, treatment of resistant hypertension includes maximization of diuretic therapy, addition of a mineralocorticoid receptor antagonist, and use of loop diuretics in patients with chronic kidney disease (CKD) 1.
Key Considerations
- The combination of different antihypertensive classes works synergistically by targeting different physiological pathways: ACE inhibitors (lisinopril) block the renin-angiotensin system, calcium channel blockers (amlodipine) relax vascular smooth muscle, and thiazide-like diuretics (chlorthalidone) reduce fluid volume 1.
- Resistant hypertension in older adults often requires 3-4 medications for adequate control, and medication adherence should be assessed as a potential contributor to treatment resistance 1.
- A team-based care approach is recommended for adults with hypertension, including the use of electronic health records and patient registries to recognize uncontrolled hypertension and guide quality improvement initiatives 1.
Recommendations
- Increase lisinopril to 40mg daily and amlodipine to 10mg daily
- Add a third agent such as chlorthalidone 25mg daily
- Monitor the patient closely with follow-up within 1-2 weeks to assess response
- Consider adding a fourth agent such as spironolactone 25mg daily or hydralazine 25mg three times daily if blood pressure remains uncontrolled 1
From the FDA Drug Label
The recommended initial dose is 10 mg once a day. Dosage should be adjusted according to blood pressure response. The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose. The usual initial antihypertensive oral dose of Amlodipine besylate tablets is 5 mg once daily, and the maximum dose is 10 mg once daily.
The patient is currently taking 20 mg of lisinopril and 5 mg of amlodipine, with a blood pressure of 200/100.
- The dosage of lisinopril is within the recommended range, but the blood pressure is not controlled.
- The dosage of amlodipine is at the minimum recommended dose for adults. Considering the patient's blood pressure is not controlled, the dosage of lisinopril could be increased up to 40 mg per day, and/or the dosage of amlodipine could be increased up to 10 mg per day. However, this decision should be made by a healthcare professional, taking into account the patient's individual needs and medical history 2, 3.
From the Research
Patient Profile
- 61-year-old male with hypertension (HTN)
- Blood pressure (BP): 200/100 mmHg
- Current medication: 5 mg amlodipine and 20 mg lisinopril
Treatment Options
- According to 4, more than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents
- The study 5 suggests that adding a thiazide diuretic (bendrofluazide) to amlodipine and lisinopril can cause a significant fall in blood pressure compared to adding a beta-blocker (atenolol) or placebo
- Combination therapy with amlodipine and an angiotensin-converting enzyme inhibitor (ACEI) like lisinopril has been shown to be effective in reducing blood pressure 6, 7
Potential Next Steps
- Consider adding a thiazide diuretic to the patient's current medication regimen, as suggested by 5
- Evaluate the patient's response to the current combination therapy and consider adjusting the doses or adding another agent if necessary, as recommended by 4 and 6
- Monitor the patient's blood pressure and adjust the treatment plan accordingly to achieve optimal blood pressure control 8, 7