From the Guidelines
For a patient on lisinopril 10 mg and amlodipine (Norvasc) 5 mg with blood pressure still in the 160/100 range, I recommend increasing the lisinopril to 20 mg daily while maintaining the amlodipine at 5 mg, as this approach is supported by the 2020 international society of hypertension global hypertension practice guidelines 1. This guideline suggests that patients with grade 2 hypertension (≥160/100mmHg) should start drug treatment immediately, and increasing the dose of existing medications is a reasonable next step. The patient's current blood pressure is significantly above the recommended threshold, and increasing the lisinopril dose is likely to provide additional blood pressure lowering effects. If blood pressure remains uncontrolled after 2-4 weeks, consider increasing amlodipine to 10 mg daily, as both medications work through complementary mechanisms - lisinopril blocks the renin-angiotensin system while amlodipine is a calcium channel blocker that causes vasodilation. Key considerations in managing this patient's hypertension include:
- Ensuring the patient is taking medications consistently
- Following a low-sodium diet
- Exercising regularly
- Limiting alcohol
- Measuring blood pressure correctly at home Additionally, monitoring for side effects such as dizziness, ankle swelling, or cough is crucial when increasing the doses of these medications. If blood pressure remains elevated despite maximizing these two medications, adding a third agent such as a thiazide diuretic (like hydrochlorothiazide 12.5-25 mg daily) would be a reasonable next step, as suggested by the prevention, detection, evaluation, and management of high blood pressure in adults guideline 2.
From the FDA Drug Label
The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose. Dosage should be adjusted according to blood pressure response. The recommended initial antihypertensive oral dose of Amlodipine besylate tablets is 5 mg once daily, and the maximum dose is 10 mg once daily. Adjust dosage according to blood pressure goals.
The patient's current dosage of lisinopril 10mg and amlodipine 5mg may not be sufficient to control their blood pressure, which is still in the 160/100 range.
- Consider increasing the dose of lisinopril to 20mg per day, as the usual dosage range is 20mg to 40mg per day.
- Alternatively, consider increasing the dose of amlodipine to 10mg per day, as the maximum dose is 10mg once daily.
- It is also possible to consider adding a diuretic to the patient's regimen, as stated in the lisinopril label 3.
- The patient's blood pressure should be closely monitored after any adjustments to their medication regimen. [3] [4]
From the Research
Patient's Current Medication and Blood Pressure
- The patient is currently taking lisinopril 10mg and norvasc 5mg, but still has a blood pressure in the 160/100 range.
- According to 5, lisinopril is effective in lowering blood pressure in all grades of essential hypertension, but the patient's current dosage may not be sufficient.
Recommendations for Adjusting Medication
- Increasing the dosage of lisinopril or adding another medication, such as hydrochlorothiazide, may be necessary to achieve adequate blood pressure reduction, as suggested by 5 and 6.
- Combination therapy with a calcium channel blocker, such as amlodipine, and an ACE inhibitor, such as lisinopril, can be effective in lowering blood pressure, as shown in 7.
- The study in 8 found that different combinations of antihypertensive therapy, including lisinopril with or without hydrochlorothiazide and amlodipine, were equally effective in reducing blood pressure and improving arterial stiffness.
Considerations for Treatment
- The patient's blood pressure is currently above the recommended target, and adjusting the medication regimen may be necessary to reduce the risk of cardiovascular disease, as discussed in 9.
- The choice of medication and dosage should be individualized based on the patient's specific needs and medical history, as well as the potential for adverse effects and interactions with other medications.
- Studies such as 6 and 8 demonstrate the importance of finding the right combination and dosage of medications to effectively manage blood pressure.