What is the best option for adjusting the medication regimen for a patient with lower extremity (LE) edema and elevated blood pressure, currently taking Losartan (Angiotensin II receptor antagonist) 100 mg, Hydrochlorothiazide (HCTZ) (Thiazide diuretic) 25 mg, Spironolactone (Potassium-sparing diuretic) 50 mg, Amlodipine (Calcium channel blocker) 10 mg, and Benazepril (Angiotensin-converting enzyme inhibitor) 20 mg?

From the Guidelines

The best option for this patient with lower extremity edema and elevated blood pressure would be to discontinue Benazepril, as using both an ACE inhibitor (Benazepril) and an ARB (Losartan) simultaneously creates unnecessary therapeutic duplication and increases the risk of hyperkalemia and renal dysfunction without providing significant additional benefit, as suggested by the guidelines reviewed in 1. This approach is supported by the lack of consensus on the optimal antihypertensive drug class for initiating treatment, with various guidelines such as AHA/ACC/CDC, ASH/ISH, and NICE suggesting different initial treatments, but all agreeing on the importance of avoiding combinations that increase the risk of adverse effects, such as combining ACEI and ARB 1. The patient's current regimen includes Losartan 100 mg, HCTZ 25 mg, Spironolactone 50 mg, Amlodipine 10 mg, and Benazepril 20 mg, which can be optimized by removing the redundant ACE inhibitor. Key considerations include:

• Discontinuing Benazepril to avoid therapeutic duplication and potential adverse effects, as there is no conclusive clinical evidence to demonstrate that a specific drug class is superior, and most guidelines recommend against combining ACEI and ARB due to increased risk of end-stage renal disease and stroke, as seen in the ONTARGET and ALTITUDE studies 1.
• Maintaining Losartan, as ARBs typically have fewer side effects, such as cough, compared to ACE inhibitors.
• Adjusting the diuretic regimen, potentially increasing HCTZ to 50 mg daily to better address edema, while closely monitoring potassium levels due to concurrent Spironolactone use.
• Retaining Amlodipine at 10 mg, as it provides effective blood pressure control through a different mechanism. After making these adjustments, it is crucial to reassess the patient within 1-2 weeks to evaluate blood pressure control, edema status, and obtain laboratory tests to check renal function and electrolytes, following the recommended timeframes for adjusting treatments suggested by guidelines such as JNC 8, ASH/ISH, AHA/ACC/CDC, ESH/ESC, and CHEP, which recommend reviewing and modifying dose and antihypertensive treatments every 2–4 weeks until an appropriate regimen is established 1.

From the FDA Drug Label

The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure [see CLINICAL STUDIES (14.1)]. The 10 mg and 25-mg doses produced some effect at peak (6 hours after dosing) but small and inconsistent trough (24 hour) responses Doses of 50 mg, 100 mg and 150 mg once daily gave statistically significant systolic/diastolic mean decreases in blood pressure, compared to placebo in the range of 5.5 to 10.5/3.5 to 7. 5 mmHg, with the 150-mg dose giving no greater effect than 50 mg to 100 mg.

The patient is already taking the maximum dose of Losartan (100 mg). Considering the patient's elevated blood pressure (152/97) and LE edema, the best option for adjustments would be to:

• Optimize the dose of HCTZ or consider alternative diuretics to manage edema.
• Consider adjusting the dose of Amlodipine or Benazepril to better control blood pressure.
• Monitor the patient's potassium levels due to the concomitant use of Spironolactone and Losartan. 2 2

From the Research

Patient's Current Medication Regimen

The patient is currently taking:

• Losartan 100 mg (Angiotensin II receptor antagonist)
• Hydrochlorothiazide (HCTZ) 25 mg (Thiazide diuretic)
• Spironolactone 50 mg (Potassium-sparing diuretic)
• Amlodipine 10 mg (Calcium channel blocker)
• Benazepril 20 mg (Angiotensin-converting enzyme inhibitor)

Patient's Condition

The patient is experiencing lower extremity (LE) edema and has elevated blood pressure (152/97 mmHg).

Potential Causes of Edema

According to 3, edema can be caused by various factors, including:

• Medications (e.g., antihypertensives, anti-inflammatory drugs, hormones)
• Chronic venous insufficiency
• Heart failure
• Lymphedema

Treatment Options

Considering the patient's current medication regimen and condition, potential treatment options include:

• Adjusting the dosage of current medications
• Adding or substituting medications to better manage blood pressure and edema
• Using diuretics to reduce fluid retention and edema, as suggested by 4

Medication Adjustments

Based on the studies, potential medication adjustments include:

• Increasing the dosage of Losartan or adding another antihypertensive medication to better control blood pressure, as shown in 5 and 6
• Adjusting the dosage of HCTZ or substituting it with another diuretic, such as chlorthalidone or indapamide, as discussed in 4
• Continuing or adjusting the dosage of Spironolactone, considering its benefits in reducing proteinuria and edema, as mentioned in 4

Considerations

When making medication adjustments, it is essential to consider the potential effects on lipid metabolism, as discussed in 5, and to monitor the patient's blood pressure, edema, and overall condition, as suggested by 7.