From the Guidelines
For this 40-year-old female patient with uncontrolled hypertension despite losartan 25mg, I would recommend adding a thiazide diuretic such as hydrochlorothiazide 12.5mg daily while maintaining her current losartan dose. This approach is supported by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, which recommend combining drugs from different classes to achieve greater blood pressure reduction. The combination of losartan, an angiotensin II receptor antagonist, and hydrochlorothiazide, a thiazide diuretic, works synergistically to lower blood pressure by reducing fluid volume and blocking the renin-angiotensin system.
The patient's current blood pressure of 127/93mmHg indicates that her diastolic pressure remains significantly elevated above the goal of <90mmHg. Adding hydrochlorothiazide to her current regimen is preferable to increasing the losartan dose, given her concerns about tachycardia with higher doses of losartan. The low starting dose of hydrochlorothiazide minimizes side effects like electrolyte disturbances while still providing therapeutic benefit.
Key considerations in managing this patient's hypertension include:
- Monitoring her blood pressure at home for two weeks after starting this combination therapy
- Checking electrolytes within 2-4 weeks
- Scheduling a follow-up appointment in one month to assess efficacy
- Considering the addition of a calcium channel blocker like amlodipine 5mg daily if this combination proves insufficient
It's also important to note that the 2020 International Society of Hypertension global hypertension practice guidelines 1 recommend optimizing the current treatment regimen, including health behavior change and diuretic-based treatment, before adding additional agents. However, in this case, the patient is already on a single agent, and adding a second agent from a different class is a reasonable next step. 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 also supports the use of combination therapy in patients with uncontrolled hypertension.
From the FDA Drug Label
The majority of the children had hypertension associated with renal and urogenital disease. The sitting diastolic blood pressure (SiDBP) on entry into the study was higher than the 95th percentile level for the patient’s age, gender, and height. At the end of three weeks, losartan reduced systolic and diastolic blood pressure, measured at trough, in a dose-dependent manner Overall, the two higher doses (25 mg to 50 mg in patients <50 kg; 50 mg to 100 mg in patients ≥50 kg) reduced diastolic blood pressure by 5 to 6 mmHg more than the lowest dose used (2.5 mg in patients <50 kg; 5 mg in patients ≥50 kg).
The next step for the 40-year-old female patient with primary hypertension on 25mg of losartan, with an average blood pressure of 127/93mmHg, which is not at goal, and who is hesitant to increase her losartan dose due to previous experiences of tachycardia is to consider alternative antihypertensive agents. Since the patient has experienced tachycardia with higher doses of losartan in the past, increasing the dose may not be the best option.
- Add a low-dose diuretic, such as hydrochlorothiazide, to the patient's current regimen, as this combination has been shown to be effective in reducing blood pressure 2.
- Consider adding a calcium-channel blocker or an alpha-blocker to the patient's treatment regimen, as these agents have been used in combination with losartan to achieve blood pressure goals 2.
- Monitor the patient's blood pressure and heart rate closely to determine the effectiveness of the new treatment regimen and to minimize potential side effects.
From the Research
Next Steps for Hypertension Management
The patient's average blood pressure of 127/93mmHg is not at goal, and she is hesitant to increase her losartan dose due to previous experiences of tachycardia. Considering this, the next steps could be:
- Adding a calcium channel blocker (CCB) to the patient's current losartan regimen, as studies have shown that combination therapy can be more effective in controlling blood pressure than monotherapy 3, 4.
- Considering a single-pill combination of an angiotensin II receptor blocker (ARB), a CCB, and a diuretic, which may improve adherence and blood pressure control 5.
- Evaluating the use of amlodipine, a CCB, as an alternative or addition to losartan, as it has been shown to have beneficial effects on blood pressure control and may have a more favorable side effect profile for this patient 6, 7.
- Monitoring the patient's blood pressure and adjusting the treatment plan as needed to achieve optimal blood pressure control.
Considerations for Combination Therapy
When considering combination therapy, it's essential to:
- Choose agents with complementary mechanisms of action to maximize blood pressure reduction 3, 4.
- Select agents with a favorable side effect profile to minimize adverse effects and improve adherence 6, 7.
- Monitor blood pressure regularly to adjust the treatment plan as needed and ensure optimal blood pressure control.
Alternative Treatment Options
If the patient is still hesitant to increase her losartan dose or add another agent, alternative treatment options could be explored, such as: