What additional antihypertensive medication can be used in a patient with uncontrolled hypertension on Coreg (carvedilol)?

From the Guidelines

For a patient with uncontrolled hypertension on carvedilol (Coreg), adding an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) would be an appropriate next step, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This approach is supported by the guidelines, which suggest that combining drugs from different classes can have additive or synergistic effects, leading to greater blood pressure reduction. The major four drug classes, including ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide or thiazide-like diuretics, are recommended as first-line blood pressure-lowering medications, either alone or in combination.

Some key points to consider when adding an ACE inhibitor or ARB to carvedilol include:

• Medications like lisinopril (10-40 mg daily), enalapril (5-40 mg daily in divided doses), or losartan (25-100 mg daily) work well with carvedilol because they target different blood pressure control mechanisms.
• Since carvedilol is a beta-blocker that reduces cardiac output and peripheral resistance, adding a medication that affects the renin-angiotensin-aldosterone system provides complementary action.
• If this combination is insufficient, a thiazide diuretic such as hydrochlorothiazide (12.5-25 mg daily) or chlorthalidone (12.5-25 mg daily) could be added as a third agent.
• For patients with comorbidities like diabetes or chronic kidney disease, an ACE inhibitor or ARB would be particularly beneficial due to their renoprotective effects, as noted in the 2015 American Heart Association statement on the treatment of hypertension in patients with coronary artery disease 1.

It's essential to monitor for potential side effects when combining these medications, including checking electrolytes and kidney function regularly, especially when initiating therapy or adjusting doses. By following the guidelines and considering the patient's individual needs and comorbidities, healthcare providers can develop an effective treatment plan to manage uncontrolled hypertension in patients taking carvedilol.

From the FDA Drug Label

In a double-blind study (GEMINI), Carvedilol Tablet, added to an ACE inhibitor or angiotensin receptor blocker, was evaluated in a population with mild-to-moderate hypertension and well-controlled type 2 diabetes mellitus. Background treatment included ACE inhibitors or angiotensin receptor blockers (97%), anticoagulants (20%), lipid-lowering agents (23%), and diuretics (34%).

The patient remains hypertensive on Coreg (carvedilol), an ACE inhibitor or angiotensin receptor blocker can be used as an additional antihypertensive medication, as evidenced by the GEMINI study where Carvedilol Tablet was added to an ACE inhibitor or angiotensin receptor blocker 2.

• Key options include:
  • ACE inhibitors
  • Angiotensin receptor blockers
  • Diuretics (as part of background treatment) Note that the choice of additional medication should be based on individual patient characteristics and clinical judgment.

From the Research

Additional Antihypertensive Medication Options

In a patient with uncontrolled hypertension on Coreg (carvedilol), several additional antihypertensive medication options can be considered:

• Thiazide diuretics, such as chlortalidone or hydrochlorothiazide, which have been shown to be effective in reducing blood pressure and preventing cardiovascular complications 3
• Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, which can be used as an alternative to thiazide diuretics 3
• Calcium channel blockers, such as amlodipine, which can be used in combination with ACE inhibitors or as a substitute for them 4, 5
• Angiotensin receptor blockers (ARBs), which can be used as an alternative to ACE inhibitors 6

Combination Therapy

Combination therapy with two or more antihypertensive agents can be considered for patients with uncontrolled hypertension on monotherapy:

• A combination of a thiazide diuretic and an ACE inhibitor or ARB can be effective in reducing blood pressure and preventing cardiovascular complications 6
• A combination of a calcium channel blocker and an ACE inhibitor or ARB can also be effective 4
• The addition of a new medication to the existing regimen can be associated with a slightly larger reduction in blood pressure, but may also be associated with less intensification sustainability 7

Specific Patient Populations

In specific patient populations, such as those with diabetes, chronic kidney disease, or heart failure, certain antihypertensive medications may be preferred:

• In patients with diabetes, an ACE inhibitor or ARB may be preferred due to their protective effects on the kidneys 6
• In patients with chronic kidney disease, a combination of an ACE inhibitor or ARB and a thiazide diuretic may be effective in reducing blood pressure and slowing disease progression 6
• In patients with heart failure, a combination of a beta blocker, an ACE inhibitor or ARB, and a diuretic may be effective in reducing blood pressure and improving outcomes 6