What to do for a 45-year-old patient with uncontrolled hypertension (HTN) and worsening symptoms of dizziness and tinnitus after starting amlodipine (calcium channel blocker) and atorvastatin (HMG-CoA reductase inhibitor)?

Management of Uncontrolled Hypertension with Dizziness and Tinnitus After Starting Amlodipine and Atorvastatin

Discontinue amlodipine and switch to an angiotensin receptor blocker (ARB) as the first-line antihypertensive agent, as the patient's symptoms of dizziness and tinnitus are likely adverse effects of amlodipine. 1

Evaluation of Current Symptoms

The patient's symptoms of dizziness and tinnitus that worsened after starting amlodipine and atorvastatin strongly suggest medication-related adverse effects. Amlodipine, a dihydropyridine calcium channel blocker (CCB), is a common cause of these symptoms due to its vasodilatory effects.

Key considerations:

• Dizziness is a known side effect of amlodipine
• Tinnitus can occur with calcium channel blockers
• Symptoms worsened temporally after starting these medications
• Uncontrolled hypertension despite medication suggests ineffective therapy or adverse effects limiting compliance

Management Algorithm

Step 1: Medication Adjustment

• Discontinue amlodipine immediately
• For non-black patients, switch to a low-dose ARB (e.g., losartan 50 mg daily) 1
• Consider temporarily continuing atorvastatin but at a lower dose (5-10 mg) to determine if it's contributing to symptoms
• If symptoms persist after ARB initiation, consider atorvastatin as a potential contributor

Step 2: Follow-up and Monitoring

• Reassess BP and symptoms within 2 weeks
• Target BP should be <140/90 mmHg 1
• Monitor for resolution of dizziness and tinnitus

Step 3: Titration and Combination Therapy (if needed)

• If BP remains uncontrolled on ARB monotherapy:
  • Increase ARB to full dose
  • Add a thiazide/thiazide-like diuretic if BP still not at goal 1
  • Consider adding spironolactone as a fourth agent if needed 1

Rationale for Medication Selection

ARBs are preferred over amlodipine in this case because:

1. They have fewer side effects related to dizziness and tinnitus
2. They provide effective BP control
3. They have favorable long-term cardiovascular outcomes

According to the 2020 International Society of Hypertension guidelines, ARBs are recommended as first-line therapy for non-black patients with hypertension 1. The 2024 ESC guidelines also support this approach 1.

Important Considerations

• Avoid non-dihydropyridine CCBs (diltiazem, verapamil) as they have negative inotropic properties 1
• If the patient is black, consider a combination of ARB with a thiazide diuretic instead of ARB monotherapy 1
• If symptoms persist despite medication changes, consider ambulatory blood pressure monitoring (ABPM) to better characterize the hypertension pattern
• Evaluate for secondary causes of hypertension if BP remains difficult to control despite multiple medications

Caution

• Do not abruptly stop all antihypertensive medications without replacement
• Ensure close follow-up during medication transitions
• If severe dizziness occurs, assess for orthostatic hypotension by checking BP in both sitting and standing positions

By switching from amlodipine to an ARB, the patient's symptoms of dizziness and tinnitus should improve while maintaining effective blood pressure control.