What is the best initial medication for a 79-year-old man with hypertension (High Blood Pressure) and chronic renal insufficiency (Impaired Renal Function)?

Angiotensin Receptor Blocker (ARB) is the First-Line Treatment for Hypertension in an Elderly Patient with Chronic Renal Insufficiency

For a 79-year-old man with hypertension and chronic renal insufficiency with proteinuria, an Angiotensin Receptor Blocker (ARB) should be prescribed as first-line therapy. 1

Rationale for ARB Selection

The 2020 International Society of Hypertension (ISH) guidelines specifically recommend ARBs as first-line therapy for patients with chronic kidney disease (CKD), particularly those with proteinuria. This recommendation is based on several factors:

1. Renoprotective Effects: ARBs provide protection against progression of renal disease beyond their blood pressure-lowering effects 1, 2

2. Proteinuria Reduction: ARBs effectively reduce proteinuria, which is a marker of kidney damage and a risk factor for progression of renal disease 3

3. Elderly Patient Considerations: At 79 years old, the patient requires medication that is well-tolerated with once-daily dosing to improve adherence 1

4. Mortality Benefit: ARBs have demonstrated reduction in cardiovascular morbidity and mortality in high-risk patients 3

Specific ARB Recommendation

Losartan is an appropriate ARB choice for this patient:

• Starting dose: 25-50 mg once daily (lower starting dose recommended due to age and renal insufficiency) 3
• Maximum dose: Can be titrated up to 100 mg daily based on blood pressure response 3
• Specific indication: FDA-approved for treatment of diabetic nephropathy with elevated serum creatinine and proteinuria 3

Alternative Options

If ARBs are not tolerated or contraindicated:

1. ACE Inhibitors: Would be an alternative first choice, as they also provide renoprotection in CKD patients 1, 2

   • However, ACE inhibitors have a higher incidence of cough as a side effect, which may affect adherence in elderly patients 4

2. Calcium Channel Blockers (DHP-CCB): Can be added as a second agent if blood pressure control is not achieved with ARB monotherapy 1

3. Thiazide-like Diuretics: May be added as a third agent, but should be used cautiously in renal insufficiency 1, 4

Monitoring Recommendations

• Blood Pressure Target: <130/80 mmHg, but individualized based on frailty and tolerability in this elderly patient 1
• Renal Function: Monitor serum creatinine and potassium within 1-2 weeks of initiation and with dose increases 3
• Proteinuria: Follow urinary protein excretion to assess response to therapy
• Orthostatic Hypotension: Check for postural blood pressure drops, especially in this elderly patient 1

Important Considerations and Pitfalls

• Avoid NSAIDs: These can worsen renal function and reduce ARB effectiveness
• Potassium Monitoring: ARBs can cause hyperkalemia, especially in renal insufficiency
• Volume Status: Ensure patient is not volume depleted before initiating therapy 3
• Dose Adjustment: Start with lower doses in elderly patients and those with renal impairment 1, 3
• Combination Therapy: Most patients with CKD will eventually require multiple agents to achieve target blood pressure 1

By following these recommendations, the patient should experience improved blood pressure control while receiving renoprotective benefits that may slow the progression of his renal disease and reduce cardiovascular risk.