What management approach is recommended for a patient with hypertension and neuropathic symptoms who declines most medications?

Management of Hypertension and Neuropathic Symptoms in a Patient with Medication Adherence Concerns

For this 70-year-old male patient with uncontrolled hypertension (174/82 mmHg) and neuropathic symptoms who declines most medications but will accept amlodipine if it's keep-on-person (KOP), restarting amlodipine 5 mg daily as KOP medication is the recommended first-line approach, along with non-pharmacological interventions for both conditions.

Hypertension Management

Pharmacological Approach

• Amlodipine 5 mg daily is an appropriate choice for this patient given:
  • Previous prescription history (since 2016)
  • Patient's willingness to take it if provided as KOP
  • Strong evidence supporting calcium channel blockers as effective first-line agents for hypertension 1
  • Amlodipine's once-daily dosing simplifies the regimen, improving adherence potential 2
  • Demonstrated effectiveness in reducing blood pressure with minimal side effects 3

Blood Pressure Target

• Target blood pressure should be <140/90 mmHg, with consideration for <130/80 mmHg if tolerated 4, 1
• Regular follow-up is essential to monitor effectiveness and potentially adjust dosage if needed

Non-Pharmacological Interventions for Hypertension

• Implement lifestyle modifications that have demonstrated BP-lowering effects:
  • Dietary modifications: Recommend DASH diet with reduced sodium intake (<2,300 mg/day) and increased potassium intake (3,500-5,000 mg/day) 1, 5
  • Physical activity: The patient already walks daily, which is beneficial; encourage continued regular aerobic exercise 1, 6
  • Weight management: If applicable, aim for BMI 20-25 kg/m² (each 1 kg weight loss can reduce systolic BP by approximately 1 mmHg) 1
  • Alcohol moderation: Advise limiting alcohol to <21 units/week with alcohol-free days 4, 1

Management of Neuropathic Symptoms

Non-Pharmacological Approaches

• Continue with Epsom salt foot baths at bedtime as planned
• Moisturizer cream for foot care as planned
• Referral to CDP (Chronic Disease Program) as planned is appropriate for comprehensive evaluation
• Consider recommending:
  • Proper footwear with cushioning
  • Regular foot inspection
  • Gentle foot exercises to improve circulation

Monitoring and Follow-up

• Schedule regular follow-up appointments to:
  • Monitor blood pressure response to amlodipine
  • Assess improvement in neuropathic symptoms
  • Encourage laboratory testing at future visits to evaluate for underlying causes of neuropathy
  • Consider home blood pressure monitoring if feasible 1

Special Considerations

Medication Adherence

• Providing amlodipine as KOP addresses the patient's specific concern about pill call
• Simplify the regimen with once-daily dosing
• Educate the patient about the importance of consistent medication use 1, 7
• Consider using pill boxes or reminder systems if appropriate

Potential Pitfalls

1. Orthostatic hypotension: Monitor for this side effect, especially in elderly patients 1
2. Peripheral edema: Common side effect of amlodipine that may affect adherence; monitor and address if it occurs 2
3. Inadequate blood pressure control: If amlodipine 5 mg is insufficient, consider:
   • Increasing to amlodipine 10 mg daily if tolerated
   • Adding another agent that patient might accept as KOP if necessary
4. Undiagnosed causes of neuropathy: The referral to CDP should include evaluation for diabetes, vitamin deficiencies, and other potential causes

Laboratory Testing

• While the patient declined laboratory testing at this visit, continue to encourage basic workup at future visits to evaluate:
  • Renal function
  • Electrolytes
  • Glucose/HbA1c
  • Lipid profile

This approach balances evidence-based management of hypertension with practical considerations of the patient's preferences and adherence concerns, while also addressing his neuropathic symptoms through appropriate non-pharmacological means and specialist referral.