From the Guidelines
For a patient with hypertension already on labetalol (beta blocker) and lisinopril (ACE inhibitor), a calcium channel blocker such as amlodipine would be an appropriate third agent to add, as it promotes vasodilation and addresses a different mechanism of blood pressure control 1. This combination is supported by the 2015 American Heart Association, American College of Cardiology, and American Society of Hypertension guidelines, which suggest that a thiazide or thiazide-like diuretic, or a calcium channel blocker, can be added to a beta blocker and an ACE inhibitor for improved blood pressure control 1. The 2018 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline also supports the use of calcium channel blockers as an add-on therapy for patients with uncontrolled hypertension, with amlodipine being a commonly used option 1. Amlodipine is typically started at 5 mg once daily and can be increased to 10 mg daily if needed. When adding amlodipine, monitor for peripheral edema, which is a common side effect, and assess the patient for orthostatic hypotension with the addition of each new antihypertensive medication. If additional therapy is needed, a thiazide diuretic like hydrochlorothiazide (12.5-25 mg daily) could be considered as a fourth agent, as suggested by the guidelines 1. This multi-drug approach follows the principle of using complementary mechanisms at moderate doses rather than maximizing a single agent, which often improves efficacy while minimizing side effects. Key considerations when using amlodipine include its potential to cause peripheral edema, and the need to monitor renal function and potassium levels, especially in patients with chronic kidney disease 1. Overall, the addition of amlodipine to labetalol and lisinopril is a reasonable and evidence-based approach to managing hypertension in patients who are not adequately controlled on two agents.
From the Research
Additional Antihypertensive Medication Options
When a patient is already taking labetalol (beta blocker) and Lisinopril (angiotensin-converting enzyme (ACE) inhibitor) and still experiences hypertension, several other antihypertensive medications can be considered.
- Amlodipine, a calcium channel blocker, has been shown to have a marked additional effect on blood pressure when used in combination with Lisinopril 2.
- Other options may include thiazide diuretics, as their use in combination with ACE inhibitors or ARBs is efficacious in black patients 3.
- The choice of additional medication should be based on the patient's individual clinical presentation and response to treatment.
Considerations for Specific Patient Populations
- Black patients may have a reduced blood pressure response to ACE inhibitors or ARBs compared to white patients, but combination therapy with a calcium channel blocker or thiazide diuretic can be effective 3.
- The response to amlodipine tends to be greater in patients with higher initial blood pressure 2.
- The response to Lisinopril is greater in patients with higher plasma renin activity 2.
Monitoring and Adjusting Treatment
- Regular monitoring of blood pressure is essential to assess the effectiveness of treatment and make adjustments as needed.
- The use of antihypertensive agents should be tailored to the individual patient's response, and adjustments should be made based on clinical presentation and blood pressure control.