From the Guidelines
For a 95-year-old female with stage 2 hypertension already on amlodipine and lisinopril, the best approach is to optimize her current regimen while carefully considering her advanced age, targeting a blood pressure goal of around 140-150/90 mmHg.
Current Regimen Optimization
To manage her stage 2 hypertension effectively, it's crucial to first ensure her blood pressure goal is appropriate for her age. The current regimen of amlodipine and lisinopril should be optimized by considering an increase in the doses of these medications if tolerated before adding any new agents 1.
Addition of New Agents
If additional therapy is needed, a low-dose thiazide diuretic like chlorthalidone 12.5mg daily could be considered, as recommended by recent guidelines 1. However, it's essential to monitor for orthostatic hypotension, electrolyte abnormalities (particularly potassium), and renal function closely with any medication adjustments.
Lifestyle Modifications
Implementing lifestyle modifications such as sodium restriction to <2g daily and light physical activity as tolerated is also crucial 1. Medication timing may also be optimized, with evening dosing of at least one antihypertensive to address nocturnal hypertension common in elderly patients.
Consideration of Comorbidities
Her hypothyroidism should be assessed to ensure adequate levothyroxine dosing, as uncontrolled hypothyroidism can contribute to hypertension. This approach balances hypertension management with the increased risk of adverse effects in very elderly patients, where excessive blood pressure lowering can lead to falls, cognitive impairment, and decreased quality of life.
Key Considerations
- Optimize current medication regimen before adding new agents.
- Monitor closely for potential side effects such as orthostatic hypotension and electrolyte imbalances.
- Lifestyle modifications are key in managing hypertension in the elderly.
- Consider comorbidities such as hypothyroidism in the management plan. Given the most recent and highest quality study available 1, this approach prioritizes the patient's morbidity, mortality, and quality of life, ensuring that the management of her stage 2 hypertension is both effective and safe.
From the Research
Management of Stage 2 Hypertension
The patient is a 95-year-old female with stage 2 hypertension, currently on amlodipine and lisinopril, and has a history of hypothyroidism on levothyroxine 75 mcg for 2 years.
- The patient's blood pressure is 180/80 mmHg, which is above the target blood pressure for adults ≥65 years, which is <130 mmHg for systolic blood pressure 2.
- First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 2.
- The patient is already on amlodipine, a calcium channel blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, which are both first-line drug therapies for hypertension 2.
Considerations for Hypothyroidism
- Hypothyroidism is frequently accompanied by cardiac dysfunction, increased vascular resistance, and a greater prevalence of hypertension 3.
- Treatment of hypothyroidism may lead to normalization of blood pressure, although some patients may exhibit sustained hypertension 3.
- The patient is already on levothyroxine 75 mcg for 2 years, which may have contributed to the management of her hypothyroidism and potentially her hypertension.
Additional Treatment Options
- If the patient's blood pressure is not controlled on amlodipine and lisinopril, the addition of a diuretic, such as hydrochlorothiazide, may be effective in reducing blood pressure 4, 5.
- A study comparing the effects of lisinopril and hydrochlorothiazide in obese patients with hypertension found that lisinopril had a greater effect on reducing systolic blood pressure 6.
- Another study found that the combination of lisinopril and hydrochlorothiazide was superior to either agent alone in controlling blood pressure 5.