What is the management approach for a patient on Valsartan (valsartan) 160 mg per day with stage 1 hypertension (Blood Pressure 142/88 mmHg)?

From the Guidelines

The patient's current blood pressure of 142/88 mmHg is considered Grade 2 Hypertension according to the 2020 international society of hypertension global hypertension practice guidelines 1, and therefore, I recommend starting drug treatment immediately, which in this case may involve increasing the valsartan dose or adding a second antihypertensive medication. Given the patient is already on valsartan 160 mg per day, increasing the dose to 320 mg daily could be considered as a first step to achieve better blood pressure control. Some key points to consider when managing this patient's hypertension include:

• Confirming adherence to the current regimen and lifestyle modifications such as sodium restriction, regular exercise, and weight management.
• Monitoring blood pressure after 2-4 weeks to assess efficacy if the dose is escalated.
• Considering the addition of a second antihypertensive medication, such as a thiazide diuretic or a calcium channel blocker, if the blood pressure remains uncontrolled after dose escalation.
• Monitoring renal function and electrolytes after dose adjustments, particularly potassium levels, as recommended by the 2018 American College of Cardiology/American Heart Association hypertension guideline 1. The choice of antihypertensive drug therapy should be based on the patient's individual characteristics and comorbidities, with the goal of achieving a blood pressure target of <130/80 mmHg. In this case, since the patient is already on an angiotensin-receptor blocker (valsartan), adding a thiazide diuretic or a calcium channel blocker could provide complementary mechanisms of action to achieve better blood pressure control.

From the FDA Drug Label

The antihypertensive effect is substantially present within 2 weeks and maximal reduction is generally attained after 4 weeks. Doses below 80 mg were not consistently distinguished from those of placebo at trough, but doses of 80,160 and 320 mg produced dose-related decreases in systolic and diastolic blood pressure, with the difference from placebo of approximately 6 to 9 / 3 to 5 mmHg at 80 to 160 mg and 9/6 mmHg at 320 mg In a controlled trial the addition of HCTZ to valsartan 80 mg resulted in additional lowering of systolic and diastolic blood pressure by approximately 6/3 and 12/5 mmHg for 12. 5 and 25 mg of HCTZ, respectively, compared to valsartan 80 mg alone.

The patient's current blood pressure is 142/88 while taking valsartan 160 mg per day.

• The patient's systolic blood pressure is higher than desired.
• The dose of 160 mg is within the recommended dose range of 80 mg to 320 mg daily.
• Consider adding a diuretic or increasing the dose to 320 mg if additional antihypertensive effect is required, as the addition of a diuretic has a greater effect than dose increases beyond 80 mg 2.
• It is also important to consider other factors that may be contributing to the patient's high blood pressure and adjust the treatment plan accordingly.

From the Research

Patient's Current Condition

• The patient is currently taking valsartan 160 mg per day.
• The patient's blood pressure is 142/88 mmHg.

Treatment Options

• According to the study 3, adding amlodipine to valsartan 160 mg can provide additional blood pressure control.
• The study 3 found that amlodipine/valsartan 5/160 mg combination therapy resulted in a significantly greater reduction in mean sitting diastolic blood pressure (MSDBP) and mean sitting systolic blood pressure (MSSBP) compared to valsartan 160 mg monotherapy.
• Another study 4 also found that amlodipine/valsartan combination therapy provided additional blood pressure control and was well-tolerated in patients inadequately controlled with valsartan monotherapy.

Alternative Therapies

• The study 5 found that valsartan 160 mg/hydrochlorothiazide 25 mg in fixed combination provided a statistically and clinically significant additional blood pressure reduction in patients not controlled by the free combination of candesartan 32 mg and HCTZ 25 mg.
• The study 6 compared the efficacy and tolerability of various doses of valsartan +/- hydrochlorothiazide (HCTZ) versus amlodipine +/- HCTZ for maximizing blood pressure control and found that initiating therapy earlier with valsartan/HCTZ was superior to amlodipine monotherapy or amlodipine +/- HCTZ for achieving blood pressure control.

Considerations

• The study 7 suggests that fixed combinations of antihypertensive agents, such as valsartan-amlodipine-hydrochlorothiazide, can improve medication adherence and attainment of blood pressure goals.
• The choice of therapy should be individualized based on the patient's specific needs and medical history, as well as the potential for adverse effects, such as peripheral edema, which was reported in some studies 3, 4.