From the Guidelines
For this 74-year-old Maori woman with severe renal impairment and uncontrolled hypertension, I strongly recommend discontinuing Jardiance (empagliflozin) immediately and adjusting her antihypertensive medications to optimize blood pressure control while minimizing medication-related risks. The patient's current medication regimen includes candesartan, furosemide, diltiazem ER, aspirin, omeprazole, and jardiance. Given her severe renal impairment (eGFR 21ml/min), it is crucial to reassess the suitability of each medication.
- Discontinuing Jardiance (empagliflozin) is necessary as it is contraindicated with eGFR below 30 ml/min, offering minimal benefit while increasing the risk of adverse effects in severe renal impairment 1.
- Consolidating the candesartan dosing to 8mg once daily rather than 4mg twice daily can improve adherence while maintaining 24-hour coverage. However, caution is advised due to the patient's renal impairment, and close monitoring of renal function and electrolytes is essential 1.
- Increasing furosemide to 80mg daily or considering switching to torsemide, which has better bioavailability in renal impairment, may be beneficial for managing hypertension and fluid overload in this patient 1.
- Reducing diltiazem ER from 360mg to 240mg daily is recommended as high doses can accumulate with reduced renal clearance, potentially leading to adverse effects 1.
- Aspirin and omeprazole can be continued at current doses as they require no adjustment for renal function. Close monitoring of blood pressure, renal function, and electrolytes (particularly potassium) is essential within 1-2 weeks of these changes to ensure the medication adjustments are effective and safe for the patient 1.
From the Research
Medication Changes for Uncontrolled Hypertension
Given the patient's current medication regimen and uncontrolled hypertension (BP 150/90), several considerations can be made based on the provided evidence:
- The patient is already on an Angiotensin Receptor Blocker (ARB), candesartan, which is appropriate for a patient with chronic kidney disease (CKD) as it helps to reduce blood pressure and has renoprotective effects 2, 3.
- The use of a diuretic, furosemide, is also common in CKD patients for blood pressure management and as a cornerstone in CKD management 2.
- The patient is on diltiazem ER, a calcium channel blocker (CCB), which can be beneficial for blood pressure control in CKD patients, especially when used in combination with a renin-angiotensin-aldosterone system inhibitor like an ARB 4, 5.
- Considering the patient's blood pressure is not well-controlled, intensification of the current regimen or addition of another agent may be necessary. The goal blood pressure in CKD patients is generally less than 130/80 mmHg, but achieving a goal of less than 140/90 mmHg may be more realistic and is supported by some evidence 6.
- Given the patient's eGFR of 21ml/min, indicating severe CKD, careful consideration of the dosages and potential side effects of the medications is crucial. The current regimen includes aspirin, omeprazole, and jardiance, which do not directly impact blood pressure control but are important for the patient's overall management.
Potential Adjustments
Potential adjustments to the medication regimen could include:
- Increasing the dose of candesartan, if tolerated, to further reduce blood pressure.
- Adjusting the dose or type of diuretic, considering the patient's renal function and potential for electrolyte imbalances.
- Considering the addition of another antihypertensive agent, such as a beta-blocker or an alpha-blocker, if the patient's blood pressure remains uncontrolled on the current regimen.
- Monitoring the patient's blood pressure closely and adjusting the medication regimen as needed to achieve the target blood pressure goal, balancing the benefits of tight blood pressure control with the potential risks of over-treatment in a patient with significant CKD 2, 3, 6.