From the Guidelines
For a 76-year-old male with resistant hypertension on losartan 100 mg daily, I recommend adding low-dose spironolactone to existing treatment, as it is a recommended treatment for resistant hypertension. This approach is based on the most recent guidelines from the European Heart Journal, 1. The addition of spironolactone can help to further reduce blood pressure and improve outcomes.
When considering the management of resistant hypertension, it is essential to prioritize lifestyle modifications, including sodium restriction, as recommended by the American Heart Association, 1. However, in this case, the focus is on pharmacological management. The use of spironolactone as an add-on therapy is supported by the 2024 ESC guidelines, which suggest its effectiveness in reducing blood pressure in patients with resistant hypertension, 1.
Some key points to consider when managing resistant hypertension in this patient include:
- Verifying medication adherence before adding new agents
- Monitoring home blood pressure readings with a target below 130/80 mmHg
- Implementing lifestyle modifications, such as sodium restriction, regular physical activity, weight management, and limiting alcohol
- Rising slowly from sitting or lying positions to prevent orthostatic hypotension when on multiple antihypertensives
The addition of spironolactone to the patient's current regimen of losartan 100 mg daily can be an effective strategy for managing resistant hypertension, as it addresses the physiological mechanism of aldosterone antagonism, 1. If the patient is intolerant to spironolactone, alternative options, such as further diuretic therapy or the addition of bisoprolol or doxazosin, can be considered, 1.
From the FDA Drug Label
The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure [see CLINICAL STUDIES (14.1)]. The patient is already on the maximum dose of 100 mg losartan daily.
- No alternative dosing regimen for losartan is recommended for resistant hypertension in the evenings.
- No specific guidance is provided for outpatient management options of resistant hypertension in the evenings for a 76-year-old male with no other comorbidities. The FDA drug label does not provide sufficient information to determine the best course of action for managing resistant hypertension in this patient. Considering the patient is already on the maximum dose of losartan, additional therapies or alternative treatments may be necessary, but this information is not provided in the drug label 2.
From the Research
Outpatient Management Options for Resistant Hypertension
The patient in question is a 76-year-old male currently on 100 mg losartan daily with no other comorbidities, presenting with resistant hypertension.
- The current medication regimen includes an angiotensin receptor blocker (losartan), but it does not meet the criteria for resistant hypertension treatment as it lacks a diuretic and a calcium channel blocker 3, 4.
- To manage resistant hypertension, lifestyle changes such as reduced sodium and alcohol intake, regular physical activity, weight loss, and discontinuation of substances that can interfere with blood pressure control are recommended 3.
- Rationalization of current treatment, including single pill combination treatment where antihypertensive drugs should be provided at the maximum tolerated dose, is also suggested 3.
- Replacement of current drugs with a more appropriate and less difficult treatment regimen based on the patient's age, ethnicity, comorbidities, and risk of drug-drug interactions may be necessary 3.
Treatment Options
- The fourth line of treatment for patients with resistant hypertension should include mineralocorticoid receptor antagonists such as spironolactone, as demonstrated in the PATHWAY-2 trial and meta-analyses 3.
- Alternatives to spironolactone include amiloride, doxazosin, eplerenone, clonidine, and beta-blockers, as well as any other antihypertensive drugs not already in use 3.
- The use of aldosterone antagonists is associated with blood pressure control in patients treated with three or more drugs 5.
- Specific agents such as ramipril, olmesartan, chlorthalidone, amlodipine, and bisoprolol have been shown to be effective in controlling blood pressure 5.