What are the outpatient management options for a 76-year-old male with nocturnal hypertension (high blood pressure at night) and normotension (normal blood pressure) during the morning and day, currently taking 100 mg losartan (angiotensin II receptor antagonist) daily, divided into 50 mg in the morning and 50 mg at night?

From the Guidelines

For a 76-year-old male with evening hypertension but normal morning and daytime blood pressure on split-dose losartan 100mg daily, I recommend adjusting the timing of medication administration to better target the evening blood pressure elevation, taking the full 100mg dose of losartan in the evening, approximately 2-3 hours before bedtime. This approach is based on the principle of chronotherapy, which aims to synchronize the medication's peak effect with the nocturnal blood pressure rise, as suggested by the latest guidelines and research 1. The patient's current regimen of split-dose losartan may not be effectively managing the evening blood pressure elevation, and adjusting the timing of medication administration could help to better control the blood pressure and reduce the risk of cardiovascular complications. Key considerations in managing this patient's hypertension include:

• Monitoring blood pressure regularly, with readings taken in the morning, afternoon, and evening to track the pattern and response to therapy
• Implementing lifestyle interventions, such as weight loss, dietary changes, and increased physical activity, as recommended by the American Heart Association 1
• Considering the addition of other antihypertensive agents, such as long-acting calcium channel blockers, if the adjusted losartan regimen is insufficient to control the evening blood pressure elevation
• Regular follow-up every 1-2 months to assess treatment efficacy and monitor for potential side effects like orthostatic hypotension. It is also important to note that evening hypertension despite morning normotension (reverse dipping pattern) carries cardiovascular risk and warrants treatment despite normal daytime readings, as highlighted in the European Society of Hypertension guidelines 1.

From the FDA Drug Label

The 10 mg and 25-mg doses produced some effect at peak (6 hours after dosing) but small and inconsistent trough (24 hour) responses Doses of 50 mg, 100 mg and 150 mg once daily gave statistically significant systolic/diastolic mean decreases in blood pressure, compared to placebo in the range of 5.5 to 10.5/3.5 to 7. 5 mmHg, with the 150-mg dose giving no greater effect than 50 mg to 100 mg. Twice-daily dosing at 50 mg to 100 mg/day gave consistently larger trough responses than once-daily dosing at the same total dose.

The patient is currently on 100 mg losartan daily taken as 50mg morning and 50 mg at night. Twice-daily dosing at this dose range has been shown to give consistently larger trough responses than once-daily dosing. However, the label does not provide specific guidance on managing hypertension that varies by time of day.

• The current dosing regimen may be effective in managing the patient's blood pressure.
• No changes to the current regimen can be recommended based on the information provided in the label. 2

From the Research

Outpatient Management Options for Hypertension

The patient in question is a 76-year-old male with hypertension in the evenings but normotensive during the morning and day, currently on 100 mg losartan daily. The following options can be considered for outpatient management:

• Lifestyle Modifications: As suggested by 3, first-line therapy for hypertension includes lifestyle modification, such as weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption.
• Medication Adjustment: The patient is currently on losartan, an angiotensin II receptor antagonist. Studies have shown that losartan can be effective in lowering blood pressure, but its efficacy may be enhanced when combined with other medications, such as amlodipine, a calcium channel blocker 4, 5, 6.
• Alternative Medications: Amlodipine has been shown to be effective in lowering blood pressure, particularly in the evening and morning hours 4. The combination of amlodipine and losartan may be considered for patients who are not adequately controlled on losartan alone 6.
• Dose Titration: The patient's current dose of losartan is 100 mg daily, which is within the recommended range. However, the dose may need to be adjusted based on the patient's response to treatment and the presence of any side effects.

Considerations for Evening Hypertension

Evening hypertension can be a challenge to manage, as it may require adjustments to the patient's medication regimen or lifestyle habits. The following considerations can be taken into account:

• Medication Timing: The patient's losartan dose is currently split into two doses, 50 mg in the morning and 50 mg at night. Adjusting the timing of the doses may help to better control evening blood pressure.
• Lifestyle Habits: Encouraging the patient to engage in regular physical activity, maintain a healthy diet, and avoid excessive alcohol consumption in the evening may help to reduce blood pressure.
• Monitoring: Regular monitoring of the patient's blood pressure, both in the clinic and at home, can help to identify any patterns or trends in blood pressure and inform treatment decisions.