What is the best antihypertensive medication for a 94-year-old female with normal renal function (creatinine level 0.54)?

From the Guidelines

For a 94-year-old female with normal renal function, a low-dose thiazide diuretic like chlorthalidone 12.5 mg daily or hydrochlorothiazide 12.5 mg daily would be a reasonable first-line antihypertensive choice, as recommended by the American College of Physicians and American Academy of Family Physicians 1. Alternatively, a long-acting calcium channel blocker such as amlodipine 2.5 mg daily could be considered. Treatment should start at the lowest possible dose with gradual titration if needed, aiming for a target blood pressure of around 140-150/90 mmHg rather than more aggressive targets used in younger patients. This conservative approach balances the benefits of blood pressure reduction with the increased risk of adverse effects in the very elderly, including orthostatic hypotension, falls, and electrolyte disturbances. The patient should be monitored closely for side effects, particularly during the first few weeks of treatment. Blood pressure should be checked in both sitting and standing positions to assess for orthostatic changes. Despite her normal renal function, age-related physiological changes affect drug metabolism and clearance, making her more sensitive to standard doses. If blood pressure remains uncontrolled on a single agent, a second medication from a different class could be added at a low dose rather than maximizing the dose of the first medication. Some key considerations in managing hypertension in the elderly include:

• Starting with low doses and gradually titrating as needed to minimize the risk of adverse effects
• Monitoring for orthostatic changes and adjusting the treatment plan accordingly
• Considering the use of thiazide diuretics or calcium channel blockers as first-line agents, as they are generally well-tolerated in the elderly
• Avoiding the use of ACE inhibitors and ARBs in combination, as this can increase the risk of adverse effects such as hyperkalemia and acute kidney injury 1. It's also important to note that the American College of Physicians and American Academy of Family Physicians recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient 1. In terms of specific medication choices, the guidelines suggest that thiazide diuretics, ACE inhibitors, and calcium channel blockers are all reasonable options for the treatment of hypertension in the elderly 1. However, the choice of medication should be individualized based on the patient's specific needs and medical history. For example, patients with a history of heart failure may benefit from the use of ACE inhibitors or ARBs, while patients with a history of kidney disease may require more careful monitoring of their renal function when using these medications. Ultimately, the goal of treatment should be to achieve a balance between reducing blood pressure and minimizing the risk of adverse effects, while also taking into account the patient's individual needs and preferences.

From the FDA Drug Label

In hypertensive patients with normal renal function, therapeutic doses of amlodipine resulted in a decrease in renal vascular resistance and an increase in glomerular filtration rate and effective renal plasma flow without change in filtration fraction or proteinuria The best antihypertensive medication for a 94-year-old female with normal renal function (creatinine level 0.54) is amlodipine.

• Key benefits:
  • Decrease in renal vascular resistance
  • Increase in glomerular filtration rate and effective renal plasma flow
  • No change in filtration fraction or proteinuria 2

From the Research

Antihypertensive Medication Options

The best antihypertensive medication for a 94-year-old female with normal renal function (creatinine level 0.54) depends on various factors, including the patient's medical history, comorbidities, and potential interactions with other medications.

• According to 3, four main classes of medications are used in combination therapy for the treatment of hypertension: thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs).
• A study published in 4 found that a fixed-dose combination of amlodipine, valsartan, and hydrochlorothiazide (HCTZ) was effective in reducing blood pressure and providing overall blood pressure control in patients with moderate or severe hypertension.

Considerations for Older Adults

When selecting an antihypertensive medication for an older adult, it is essential to consider the potential risks and benefits of each medication.

• As noted in 5, serum creatinine levels increase with age, and this should be taken into account when interpreting creatinine values and translating them into changes in kidney function.
• The study in 6 discusses the value and pitfalls of using creatinine as a marker of kidney function and provides information on alternative functional biomarkers of the kidney.

Potential Interactions and Side Effects

It is crucial to monitor for potential interactions and side effects when prescribing antihypertensive medications, especially in older adults.

• The case series in 7 highlights the importance of early detection of rare adverse reactions, such as acute interstitial nephritis, which can be associated with certain medications.
• The study in 3 emphasizes the need to avoid using ACEIs and ARBs simultaneously and to consider the patient's medical history and comorbidities when selecting an antihypertensive medication.