From the Guidelines
For an elderly patient with hypertension already on amlodipine 10 mg daily who does not have CKD or diabetes, the best additional antihypertensive medication would be an angiotensin receptor antagonist such as losartan 50-100 mg daily, as evidenced by the LIFE trial which showed that losartan was more effective in reducing cardiovascular events, particularly stroke, than the beta-blocker atenolol in hypertensive patients with evidence of left ventricular hypertrophy 1.
When considering the addition of a second antihypertensive agent to amlodipine in an elderly patient, it's crucial to prioritize medications that have demonstrated benefits in this population. The choice between different classes of antihypertensive drugs should be guided by the patient's overall clinical profile, including the presence of comorbid conditions and potential side effects of the medications.
Key considerations in managing hypertension in the elderly include:
- Starting with lower doses and gradually titrating to minimize the risk of adverse effects, particularly orthostatic hypotension 1.
- Monitoring for electrolyte abnormalities and assessing renal function periodically, especially when initiating diuretics.
- Recognizing that thiazide diuretics, while effective, may not be the first choice for addition to amlodipine due to the potential for increased risk of electrolyte disturbances in the elderly.
- Understanding that the goal of blood pressure management in the elderly is to reduce cardiovascular morbidity and mortality, with a target blood pressure of less than 130/80 mmHg, if tolerated 1.
Given the evidence from recent guidelines and clinical trials, the addition of an angiotensin receptor antagonist like losartan to amlodipine is a reasonable and evidence-based approach for managing hypertension in elderly patients without CKD or diabetes, considering its benefits in reducing cardiovascular events, particularly in patients with left ventricular hypertrophy 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Additional Antihypertensive Medication Options
Given the patient's current regimen of amlodipine 10 mg po daily, several options can be considered to add to their treatment:
- Lisinopril: An angiotensin-converting enzyme (ACE) inhibitor, which has been shown to be effective in combination with amlodipine 2. This combination can provide a significant additional blood pressure lowering effect.
- Lercanidipine: A vasoselective dihydropyridine calcium antagonist, which has been found to be effective in treating hypertension, including in elderly patients 3. It may be considered as an alternative or additional option.
- Chlorthalidone: A diuretic that has been compared to amlodipine and lisinopril in the ALLHAT trial, showing no significant difference in cardiovascular outcomes 4. However, this study did not specifically address the addition of chlorthalidone to amlodipine.
Considerations for Elderly Patients
When selecting an additional antihypertensive medication for an elderly patient, it is essential to consider their overall health status, potential comorbidities, and the risk of adverse effects.
- Lisinopril has been shown to be well-tolerated and effective in elderly patients with hypertension 5.
- Amlodipine has also been found to be effective and well-tolerated in the elderly population 6.
- Lercanidipine has been shown to be effective in elderly patients with mild to moderate essential hypertension, and its once-daily administration may improve compliance 3.
Combination Therapy
Combination therapy with amlodipine and another antihypertensive agent, such as lisinopril, may provide a more significant blood pressure lowering effect than monotherapy 2. This approach can be considered for patients who require additional blood pressure control.