What are the outpatient management options for a 76-year-old male with nocturnal hypertension (high blood pressure at night) and normal blood pressure during the morning and day, currently taking 100 mg losartan (angiotensin II receptor antagonist) daily?

From the Guidelines

For a 76-year-old male with evening hypertension but normal morning and daytime blood pressure on losartan 100 mg daily, I recommend shifting the timing of his losartan dose from morning to evening to better control his evening blood pressure spikes. This approach is based on the understanding that evening-predominant hypertension, or reverse dipping, can increase cardiovascular risk despite normal daytime readings, as suggested by studies such as 1. The goal is to achieve 24-hour blood pressure control while minimizing side effects like orthostatic hypotension, which is particularly important in older adults.

Key Considerations

• Home blood pressure monitoring is essential, with readings taken both in the morning and evening to track the pattern and effectiveness of treatment.
• If shifting the losartan dose is insufficient after 2-4 weeks of monitoring, consider adding a low-dose thiazide diuretic like chlorthalidone 12.5 mg or hydrochlorothiazide 12.5 mg in the evening.
• Alternatively, a long-acting calcium channel blocker such as amlodipine 5 mg could be added in the evening.
• Lifestyle interventions, as outlined in 1, including weight reduction, sodium chloride reduction, alcohol consumption restriction, and regular physical activity, should always be advised for patients receiving antihypertensive drugs.

Monitoring and Follow-Up

• Regular follow-up every 1-2 months is recommended to assess treatment efficacy and adjust medications as needed.
• The use of ambulatory blood pressure monitoring (ABPM) can provide valuable insights into the patient's blood pressure patterns, including the extent of nocturnal dipping and early-morning BP surge, as discussed in 1.
• ABPM can help identify the most effective treatment strategy and minimize the risk of cardiovascular complications.

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)]. Analysis of age, gender, and race subgroups of patients showed that men and women, and patients over and under 65, had generally similar responses.

The patient is already on 100 mg losartan daily. No change in dosage is recommended based on the provided information, as the patient's blood pressure is not consistently elevated throughout the day.

• The patient's current dosage is already at the maximum recommended dose.
• There is no direct information in the drug label regarding outpatient management options for hypertension that varies by time of day.
• The patient's age (76 years) and gender (male) do not require a dose adjustment according to the label 2. However, monitoring and potential adjustments to the patient's treatment regimen may be necessary to achieve optimal blood pressure control. 2

From the Research

Outpatient Management Options

The patient is a 76-year-old male with hypertension in the evenings but normotensive during the morning and day, currently on 100 mg losartan daily with no other comorbidities. The following options can be considered:

• Switching to amlodipine, as it has been shown to be effective in reducing blood pressure variability (BPV) and has a longer duration of action, allowing for sustained blood pressure control throughout the day 3.
• Adding a low-dose diuretic, such as hydrochlorothiazide, to the current losartan regimen, as this combination has been shown to be effective in reducing blood pressure and is cost-effective 4.
• Continuing with losartan, but with closer monitoring of blood pressure and potential adjustment of the dosage or addition of another agent if necessary.

Considerations for Losartan and Amlodipine

• Losartan has been shown to have a higher office visit-to-visit average real variability (ARV) of systolic blood pressure (SBP) and higher evening day-to-day home BPV indexes compared to amlodipine 5.
• Amlodipine has been shown to have a longer duration of action and can sustain its anti-hypertensive effect for more than 24 hours following a single dose, making it a good option for patients with hypertension in the evenings 3.
• The combination of amlodipine and losartan has been shown to be tolerable and causes additive haemodynamic changes compared to monotherapy of either drug, but amlodipine significantly decreases the exposure of losartan at steady-state 6.

Pharmacokinetic and Haemodynamic Interactions

• The co-administration of amlodipine and losartan does not cause substantial pharmacokinetic interaction, although amlodipine affects the disposition of losartan 6.
• The combination of amlodipine and losartan causes additive haemodynamic changes compared to treatment with amlodipine or losartan alone 6.

Renoprotective Effects

• Losartan has been shown to have renoprotective effects in patients with chronic kidney disease and hypertension, independent of its antihypertensive action 7.