From the Guidelines
For a 65-year-old male with hypertension, hyperlipidemia, and type 2 diabetes presenting with dizziness, I recommend immediate medication adjustment and evaluation to minimize the risk of morbidity, mortality, and improve quality of life. The patient's hydrochlorothiazide dose of 100mg is significantly above the maximum recommended dose of 25-50mg daily, as stated in the 2017 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, likely contributing to his dizziness through electrolyte imbalances and volume depletion. Additionally, metoprolol 100mg twice daily may be causing excessive blood pressure reduction, which can lead to orthostatic hypotension, a common barrier to intensive blood pressure control, as noted in the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure 1. I would reduce HCTZ to 25mg daily, decrease metoprolol to 50mg twice daily, and monitor blood pressure closely. The patient should have comprehensive laboratory testing including electrolytes, renal function, and blood glucose. His Glipizide dose of 1mg before meals is unusually low (typical starting dose is 5mg), so blood glucose monitoring is essential to ensure adequate diabetes control, as recommended in the primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association 1. Orthostatic blood pressure measurements should be performed to assess for postural hypotension, as suggested in the 2017 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. The patient should be advised to rise slowly from sitting or lying positions to minimize dizziness. If symptoms persist despite medication adjustments, further evaluation for other causes of dizziness including cardiac, neurological, or vestibular disorders would be warranted. Medication-induced dizziness is common in older adults with multiple comorbidities and often requires careful titration of medications to balance disease control with side effect management. It is essential to consider the potential causes of orthostatic hypotension, including severe volume depletion, baroreflex dysfunction, autonomic insufficiency, and certain venodilator antihypertensive drugs, especially β-blockers and α-blockers, as well as diuretics and nitrates, which may further aggravate orthostatic hypotension 1.
From the FDA Drug Label
For Control of Hypertension: The adult initial dose of hydrochlorothiazide capsules is one capsule given once daily whether given alone or in combination with other antihypertensives. Total daily doses greater than 50 mg are not recommended. A greater blood pressure reduction and an increase in side effects may be observed in the elderly (i.e., >65 years) with hydrochlorothiazide. Starting treatment with the lowest available dose of hydrochlorothiazide (12.5 mg) is therefore recommended. If further titration is required, 12.5 mg increments should be utilized.
The patient is currently taking hydrochlorothiazide 100mg, which is greater than the recommended total daily dose of 50mg. Considering the patient's age (65 years old) and the potential for increased side effects, it is advisable to reduce the dose of hydrochlorothiazide to the recommended starting dose of 12.5mg and titrate as needed. The patient's dizziness may be a side effect of the high dose of hydrochlorothiazide, and reducing the dose may help alleviate this symptom 2 2.
- Key considerations:
- Reduce hydrochlorothiazide dose to 12.5mg
- Monitor patient's blood pressure and side effects
- Titrate dose as needed in 12.5mg increments
- Consider potential interactions with other medications, such as metoprolol and Glipizide.
From the Research
Patient Presentation and History
The patient is a 65-year-old male presenting with dizziness, and has a history of hypertension, hyperlipidemia, and type 2 diabetes. He is currently taking hydrochlorothiazide 100mg, metoprolol 100mg twice daily, and Glipizide 1mg before each meal.
Potential Causes of Dizziness
- Vertigo, disequilibrium, near-syncope, and nonspecific dizziness are four broad categories of dizziness 3
- Dizziness can result from a disturbance in any number of balance control systems, including the visual pathways, vestibular apparatus, cardiovascular system, and CNS 3
- The patient's medications, particularly hydrochlorothiazide, may contribute to orthostatic hypotension, a potential cause of dizziness 4, 5
Evaluation and Management
- A careful medical history and targeted physical examination are essential in evaluating dizziness 3, 6
- The physical examination should include observing the patient at rest and following simple movements or bedside tests 6
- Identifying common peripheral vestibular disorders is a priority, and can help exclude more serious central causes of dizziness 6
- The patient's medications should be reviewed, and potentially causative medications, such as hydrochlorothiazide, should be considered as a contributing factor to dizziness 4, 5
- The patient's blood pressure should be monitored, and orthostatic hypotension should be assessed, particularly given the patient's use of hydrochlorothiazide 4, 5
Considerations for Referral
- Depending on the results of the evaluation, referral to an audiologist, otolaryngologist, neurologist, cardiologist, and/or psychiatrist may be necessary for further assessment and management 3
- Physical therapists should perform thorough examinations of patients with dizziness, and properly interpret positive central signs, indicating a potential need for referral to a physician or other healthcare provider 7