What is the best option for managing blood pressure and reducing peripheral edema in a 61-year-old female with hypertension, contraindication to Angiotensin-Converting Enzyme inhibitors (ACEs) and Angiotensin Receptor Blockers (ARBs) due to worsening chronic cough, currently on amlodipine (calcium channel blocker) and hydrochlorothiazide (thiazide diuretic)?

From the Guidelines

The best option for managing blood pressure and reducing peripheral edema in this 61-year-old female with hypertension, who cannot tolerate ACE inhibitors or ARBs due to chronic cough, is to add spironolactone (aldosterone antagonist) at a starting dose of 25 mg daily to her current regimen of amlodipine and hydrochlorothiazide. This approach is supported by the 2020 international society of hypertension global hypertension practice guidelines 1, which recommend adding a low dose of spironolactone as the 4th line agent in patients whose serum potassium is <4.5 mmol/L and whose eGFR is >45 ml/min/1.73m2 to achieve BP targets. The use of spironolactone is particularly beneficial in this case because it can help address peripheral edema through its potassium-sparing diuretic effects, while also providing additional blood pressure control by blocking aldosterone receptors and reducing sodium and water retention. Key considerations include:

• Monitoring potassium levels and renal function regularly, especially during the initial weeks of therapy.
• Adjusting the dose of spironolactone based on patient response and tolerance.
• Considering alternative options such as eplerenone or beta-blockers if spironolactone is not tolerated or contraindicated. 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 diuretics, including spironolactone, in the management of hypertension, particularly in patients with fluid retention. Additionally, the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure 1 emphasizes the importance of using thiazide-type diuretics as the basis of antihypertensive therapy, and notes that adding other classes of drugs, including aldosterone antagonists like spironolactone, may be necessary to achieve blood pressure control. Overall, the addition of spironolactone to this patient's current regimen offers a complementary mechanism for blood pressure control and edema management, and is supported by recent clinical guidelines.

From the FDA Drug Label

1 INDICATIONS & USAGE 1. 1 Hypertension Amlodipine besylate tablets is indicated for the treatment of hypertension, to lower blood pressure.

INDICATIONS AND USAGE Hydrochlorothiazide capsules are indicated in the management of hypertension either as the sole therapeutic agent, or in combination with other antihypertensives.

The patient is already on amlodipine and hydrochlorothiazide, which are indicated for the treatment of hypertension. To manage blood pressure and reduce peripheral edema, the current treatment regimen could be optimized by:

• Monitoring the patient's blood pressure and edema closely
• Adjusting the dose of hydrochlorothiazide if necessary, as it may help reduce edema
• Considering alternative treatments for pain management that do not exacerbate edema, as non-steroidal anti-inflammatory drugs can reduce the diuretic, natriuretic, and antihypertensive effects of thiazide diuretics like hydrochlorothiazide 2
• Evaluating the need for additional medications or lifestyle modifications to control blood pressure and edema, as the patient's current regimen may not be sufficient to achieve optimal blood pressure goals 3

From the Research

Management of Blood Pressure and Reduction of Peripheral Edema

The patient in question is a 61-year-old female with hypertension, who has a contraindication to Angiotensin-Converting Enzyme inhibitors (ACEs) and Angiotensin Receptor Blockers (ARBs) due to worsening chronic cough. She is currently on amlodipine (calcium channel blocker) and hydrochlorothiazide (thiazide diuretic), and is experiencing dependent edema.

Current Treatment and Side Effects

• The patient is experiencing peripheral edema, a common side effect of calcium channel blockers, particularly dihydropyridine calcium channel blockers like amlodipine 4, 5, 6.
• The addition of a diuretic, such as hydrochlorothiazide, has little effect on vasodilatory edema 4.
• The combination of a calcium channel blocker and a renin-angiotensin-aldosterone system inhibitor (e.g. ACE inhibitor or ARB) can enhance blood pressure control and reduce peripheral edema, but this option is contraindicated in this patient due to worsening chronic cough 4, 5, 7.

Alternative Treatment Options

• Considering the patient's contraindication to ACEs and ARBs, alternative treatment options for managing blood pressure and reducing peripheral edema need to be explored.
• One option could be to switch to a different calcium channel blocker that is less likely to cause peripheral edema, such as lacidipine 4, 8.
• Another option could be to add a different class of medication that can help reduce peripheral edema, such as a potassium-sparing diuretic or a mineralocorticoid receptor antagonist, although the evidence for these options is limited 6.

Key Considerations

• The patient's worsening chronic cough contraindicates the use of ACEs and ARBs, which are commonly used to reduce peripheral edema in patients on calcium channel blockers 7.
• The choice of alternative treatment options should be based on the patient's individual needs and medical history, and should be guided by the available evidence and clinical guidelines.
• It is essential to monitor the patient's blood pressure and peripheral edema closely, and to adjust the treatment plan as needed to achieve optimal control of both conditions 5, 8.