What's the next step for a 67-year-old patient with hypertension, currently on lercanidipine (generic name: lercanidipine, an antihypertensive medication) 20 mg once daily (od), with morning blood pressure readings of 139/79 mmHg and evening readings of 147/81 mmHg?

Management of Hypertension in a 67-Year-Old Patient on Lercanidipine

For a 67-year-old patient with hypertension on lercanidipine 20 mg once daily with current BP readings of 139/79 mmHg in the morning and 147/81 mmHg in the evening, the next step should be to add a thiazide/thiazide-like diuretic to the current regimen.

Current Status Assessment

The patient is currently on:

• Lercanidipine 20 mg once daily (maximum dose of this dihydropyridine calcium channel blocker)
• Morning BP: 139/79 mmHg (borderline controlled)
• Evening BP: 147/81 mmHg (above target)

Blood Pressure Target Analysis

According to the 2020 International Society of Hypertension (ISH) guidelines 1:

• Target BP should be <130/80 mmHg for most patients
• For elderly patients, targets may be individualized based on frailty
• The evening BP reading of 147/81 mmHg exceeds the hypertension threshold of ≥140/90 mmHg
• The morning reading is borderline but still above optimal targets

Treatment Algorithm

The patient's current status indicates:

1. Maximum dose of lercanidipine (20 mg) has been reached
2. BP is not adequately controlled, particularly in the evening
3. Patient is 67 years old, which places them in a higher risk category

Following the ISH 2020 drug therapy steps for non-black patients 1:

1. ✓ Started with a calcium channel blocker (lercanidipine)
2. ✓ Increased to full dose (20 mg)
3. → Next step: Add a thiazide/thiazide-like diuretic

Evidence for Current Treatment

Lercanidipine is an effective dihydropyridine calcium channel blocker:

• It has a long receptor half-life and slow onset of action, which helps avoid reflex tachycardia 2
• At 20 mg/day, it has shown efficacy comparable to amlodipine 10 mg/day 3
• It is effective in elderly patients (aged 60-85 years) with mild to moderate hypertension 4

Rationale for Adding a Thiazide Diuretic

1. The patient has reached the maximum dose of lercanidipine (20 mg)
2. Evening BP readings remain elevated (147/81 mmHg)
3. The ISH 2020 guidelines specifically recommend adding a thiazide/thiazide-like diuretic as the next step after maximizing calcium channel blocker dosage 1
4. Combination therapy with different mechanisms of action provides synergistic effects

Monitoring Recommendations

After adding the thiazide/thiazide-like diuretic:

• Reassess BP control within 4 weeks
• Target should be to achieve BP <130/80 mmHg throughout the day
• Monitor for electrolyte abnormalities, particularly potassium and sodium levels
• Assess for potential side effects of the combination therapy

Common Pitfalls to Avoid

1. Inadequate dose titration: The patient is already on maximum dose of lercanidipine, so further dose increases are not an option
2. Switching medications unnecessarily: Lercanidipine appears well-tolerated as no adverse effects were mentioned, so adding a complementary agent is preferable to switching
3. Ignoring diurnal BP variations: The evening BP elevation is significant and should not be ignored
4. Delaying treatment intensification: At age 67, prompt BP control is important to reduce cardiovascular risk

If BP remains uncontrolled after adding a thiazide diuretic, the next step would be to consider adding spironolactone or another agent such as an ACE inhibitor or ARB, according to the ISH 2020 treatment algorithm 1.