What is the recommended treatment plan for a 36-year-old female with hypertension who is not responding to telmisartan (angiotensin II receptor antagonist) 80mg/12.5mg?

From the Guidelines

For a 36-year-old female with hypertension not responding to telmisartan 80mg/12.5mg, I recommend adding spironolactone 25mg daily to her regimen, as it is a recommended treatment for resistant hypertension according to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This approach is based on the most recent and highest quality evidence available. The patient's current treatment with telmisartan, an angiotensin II receptor antagonist, has not been effective in controlling her blood pressure, indicating the need for an additional agent with a different mechanism of action. Spironolactone, a mineralocorticoid receptor antagonist, is a suitable choice as it has been shown to be effective in reducing blood pressure in patients with resistant hypertension, as stated in the 2024 ESC guidelines 1. Before adding spironolactone, it is essential to confirm adherence to the current regimen and proper blood pressure measurement technique. Additionally, lifestyle modifications should be reinforced, including sodium restriction, regular physical activity, weight management, limiting alcohol consumption, and avoiding NSAIDs, which can raise blood pressure, as recommended by the 2020 International Society of Hypertension global hypertension practice guidelines 1 and the 2018 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. It is also crucial to consider secondary causes of hypertension, such as sleep apnea, renal artery stenosis, primary aldosteronism, or thyroid disorders, especially given the patient's young age and treatment resistance, as suggested by the 2018 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1. If spironolactone is not effective or tolerated, alternative treatments, such as eplerenone, bisoprolol, or doxazosin, may be considered, as recommended by the 2024 ESC guidelines 1. Regular follow-up and monitoring of blood pressure and potential side effects are necessary to adjust the treatment plan as needed. The 2018 American Heart Association scientific statement on resistant hypertension also supports the use of spironolactone as a fourth-line agent in patients with resistant hypertension 1. Overall, the addition of spironolactone to the patient's current regimen, along with lifestyle modifications and consideration of secondary causes, is a reasonable and evidence-based approach to managing her resistant hypertension.

From the FDA Drug Label

The incidence of symptomatic orthostasis after the first dose in all controlled trials was low (0. 04%). There were no changes in the heart rate of patients treated with telmisartan in controlled trials. Although the event rates in ONTARGET were similar on telmisartan and ramipril, the results did not unequivocally rule out that telmisartan may not preserve a meaningful fraction of the effect of ramipril in reducing cardiovascular events However, the results of both ONTARGET and TRANSCEND do adequately support telmisartan being more effective than placebo would be in this setting, particularly for the endpoint of time to cardiovascular death, myocardial infarction, or stroke

The patient is not responding to telmisartan 80mg/12.5mg, alternative treatment options should be considered.

• Combination therapy with other antihypertensive agents may be necessary to achieve adequate blood pressure control.
• Dose adjustment or switching to a different medication may be required.
• Lifestyle modifications, such as diet and exercise, should also be encouraged to help manage hypertension. 2

From the Research

Treatment Plan for Hypertension

The patient is a 36-year-old female with hypertension who is not responding to telmisartan 80mg/12.5mg. Based on the available evidence, the following treatment plan can be considered:

• Lifestyle modification: As recommended by 3, lifestyle modification is the first-line therapy for hypertension, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption.
• Alternative antihypertensive medication: Since the patient is not responding to telmisartan, an alternative antihypertensive medication can be considered. According to 4, telmisartan is as effective as other major classes of antihypertensive agents, but the patient may benefit from a different class of medication, such as a calcium channel blocker or a diuretic.
• Combination therapy: The patient may benefit from a combination of antihypertensive medications. As shown in 5 and 6, the combination of telmisartan and amlodipine is effective in reducing blood pressure and is well tolerated.
• Dose titration: The dose of the antihypertensive medication can be titrated to achieve the desired blood pressure level. According to 4, the maximum blood pressure reduction with telmisartan occurs at a dosage of 40 to 80 mg/day.
• Monitoring: The patient's blood pressure should be monitored regularly to assess the effectiveness of the treatment plan and to make any necessary adjustments.

Considerations

• Cardiovascular risk: The patient's cardiovascular risk should be assessed and taken into consideration when developing the treatment plan. As shown in 3 and 6, patients with high cardiovascular risk may benefit from more aggressive blood pressure management.
• Side effects: The potential side effects of the antihypertensive medications should be considered and monitored. According to 4, telmisartan is generally well tolerated, but the patient may experience side effects such as dry cough or dizziness.
• Patient education: The patient should be educated on the importance of adherence to the treatment plan and lifestyle modifications to achieve optimal blood pressure control. As recommended by 3, patient education and counseling can improve blood pressure control and reduce cardiovascular risk.