Should I add another antihypertensive medication or wait for lercanidipine to take full effect?

From the Guidelines

I recommend waiting 4-6 weeks for lercanidipine to reach its full effect before adding another antihypertensive medication, as this allows sufficient time to assess the medication's efficacy and minimize potential side effects 1. Lercanidipine, a calcium channel blocker, typically takes several weeks to achieve maximum blood pressure reduction.

Key Considerations

• During this waiting period, it is essential to monitor blood pressure regularly, ideally twice daily (morning and evening), and keep a log to track trends.
• If blood pressure remains significantly elevated after this period (consistently above 140/90 mmHg, or above the personalized target set by the doctor), then adding a second medication would be appropriate.
• Calcium channel blockers like lercanidipine work by relaxing blood vessel walls, which takes time to fully develop.
• Adding medications too quickly can lead to excessive blood pressure lowering and side effects like dizziness or fainting.

Guidelines and Recommendations

• The JNC 8 guidelines suggest that the initial dose of a drug should be at least half of the maximum recommended dose, so that only one up-titration is required to reach the maximum recommended level 1.
• The ASH/ISH guidelines recommend reviewing and modifying dose and antihypertensive treatments every 2–4 weeks until an appropriate regimen is established 1.
• Most patients with hypertension will require two or more medications to achieve goal blood pressure, and the use of multidrug combinations often produces greater blood pressure reduction at lower doses of the component agents, resulting in fewer side effects 1.

Urgent Situations

• However, if very high readings (above 180/120 mmHg), severe headaches, vision changes, or chest pain are experienced during the waiting period, immediate medical attention is necessary as the treatment plan may need urgent adjustment.

From the Research

Lercanidipine Efficacy and Combination Therapy

• Lercanidipine is a vasoselective dihydropyridine calcium antagonist that effectively reduces blood pressure in patients with mild to moderate hypertension 2, 3.
• The drug has a slower onset and longer duration of action compared to other calcium antagonists, with a response rate of 50-86% in patients with mild to moderate hypertension 2.
• Lercanidipine has been shown to be as effective as other antihypertensive agents, including atenolol, captopril, and hydrochlorothiazide, in reducing blood pressure 2, 3.

Waiting for Lercanidipine to Take Full Effect

• Since the patient has only been taking lercanidipine for 1 week, it may be beneficial to wait for a longer period to assess the full effect of the medication 2, 3.
• Studies have shown that lercanidipine can take several weeks to reach its full antihypertensive effect, with significant reductions in blood pressure observed after 4-12 weeks of treatment 2, 3, 4.

Combination Therapy with Lercanidipine

• If the patient's blood pressure remains uncontrolled after an adequate trial of lercanidipine, combination therapy with another antihypertensive agent may be considered 5.
• Lercanidipine can be combined with other classes of antihypertensive drugs, including β-blockers, diuretics, angiotensin-converting enzyme inhibitors, and angiotensin-II receptor blockers, to achieve better blood pressure control 5.
• The addition of a second drug to lercanidipine has been shown to determine an additional decrease in blood pressure, with no significant differences in the size of the blood pressure decrease observed with different classes of drugs 5.