From the Guidelines
For a 76-year-old male experiencing increased evening hypertension while on maximum losartan and tamsulosin (Flomax), I recommend adding a long-acting calcium channel blocker such as amlodipine 5mg once daily in the morning, as this approach is supported 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. This medication works well for evening blood pressure elevations and complements the existing angiotensin receptor blocker therapy. If amlodipine causes ankle swelling (a common side effect), consider a thiazide diuretic like chlorthalidone 12.5mg daily instead, as low-dose thiazides are also accepted as a first-line treatment for elderly people 1. It's essential to monitor kidney function and electrolytes after starting either medication, particularly in an older patient. The evening blood pressure elevation may represent nocturnal hypertension, which carries increased cardiovascular risk. Tamsulosin (Flomax) for presumed benign prostatic hyperplasia should be continued as it has minimal effects on blood pressure. Some key points to consider in managing this patient's hypertension include:
- Home blood pressure monitoring twice daily would be valuable to assess the effectiveness of the new regimen.
- The goal blood pressure for this patient should be around 130-139/70-79 mmHg, balancing cardiovascular protection with risk of falls in an elderly patient.
- The stepped-care approach defined by the initiation of antihypertensive drug therapy with a single agent followed by the sequential titration of the dose and addition of other agents has been the recommended treatment strategy since the first report of the National High Blood Pressure Education Program 1. However, in this case, adding a second agent is reasonable given the patient's age and the fact that they are already on maximum losartan. It is crucial to carefully monitor blood pressure to avoid hypotension or orthostatic hypotension, especially in older patients 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Profile
- 76-year-old male patient
- Increased hypertension in the evening
- Currently taking losartan (maxed) and flomax
Treatment Options
- Considering the patient is already taking an angiotensin receptor blocker (losartan), adding a calcium channel blocker or a thiazide diuretic could be a viable option 2, 3, 4
- A study comparing losartan/hydrochlorothiazide and candesartan/amlodipine combinations found similar efficacy in reducing blood pressure, with the losartan/hydrochlorothiazide combination being more cost-effective and having fewer adverse effects 5
- Triple fixed-dose combination therapy with an angiotensin II receptor blocker, a calcium channel blocker, and a thiazide diuretic may also be considered, as it has been shown to be effective in reducing blood pressure and improving compliance 6
Potential Next Steps
- Add a calcium channel blocker, such as amlodipine, to the patient's current regimen 2, 3
- Add a thiazide diuretic, such as hydrochlorothiazide, to the patient's current regimen 3, 5
- Consider switching to a triple fixed-dose combination therapy, such as olmesartan, amlodipine, and hydrochlorothiazide, if the patient's blood pressure remains uncontrolled 6