What are the criteria for holding metoprolol (Lopressor) HCTZ (hydrochlorothiazide) and lisinopril in patients with hypotension or impaired renal function?

Holding Criteria for Metoprolol, HCTZ, and Lisinopril

Beta-blockers, ACE inhibitors, and diuretics should be held when systolic blood pressure is <90 mmHg or if there is significant renal impairment with creatinine >2.5 mg/dL in men or >2.0 mg/dL in women. 1

Metoprolol Holding Criteria

Blood Pressure Criteria:

• Hold if systolic BP <90 mmHg
• Hold if signs of hypotension (dizziness, lightheadedness)
• Hold if patient shows signs of cardiogenic shock risk factors:
  • Age >70 years
  • Systolic BP <120 mmHg
  • Heart rate >110 bpm or <60 bpm 1

Cardiac/Pulmonary Criteria:

• Hold if signs of heart failure or low output state
• Hold if PR interval >0.24 seconds
• Hold if second or third-degree heart block
• Hold if active asthma or reactive airways disease 1

Hydrochlorothiazide (HCTZ) Holding Criteria

Blood Pressure/Volume Criteria:

• Hold if systolic BP <90 mmHg
• Hold if symptomatic hypotension
• Hold if signs of hypovolemia 1

Electrolyte/Renal Criteria:

• Hold if significant hypokalemia (K+ ≤3.5 mmol/L)
• Hold if significant renal dysfunction (creatinine >221 μmol/L [>2.5 mg/dL] or eGFR <30 mL/min/1.73 m²) 1
• Hold if patient has severe electrolyte abnormalities (especially hyponatremia)

Lisinopril Holding Criteria

Blood Pressure Criteria:

• Hold if systolic BP <90 mmHg
• Hold if prolonged hypotension (systolic BP <90 mmHg for more than 1 hour) 2

Renal/Electrolyte Criteria:

• Hold if acute renal failure
• Hold if creatinine clearance <10 mL/min (reduce dose by half if clearance is between 10-30 mL/min)
• Hold if hyperkalemia (K+ ≥5.0 mEq/L) 1, 2
• Hold if bilateral renal artery stenosis is suspected

Special Considerations

Combined Therapy Considerations:

• When patients are on all three medications, monitor more frequently for hypotension and renal dysfunction
• The combination of these medications increases risk of hypotension, especially in volume-depleted patients 1
• Routine combined use of ACE inhibitor, ARB, and aldosterone antagonist is not recommended due to increased risk of renal dysfunction and hyperkalemia 1

Restarting Medications:

• For patients with initial contraindications to beta-blockers, reevaluate to determine subsequent eligibility 1
• When restarting lisinopril after holding for hypotension, consider starting at half the usual dose (2.5 mg) 2
• When restarting metoprolol, consider using lower doses (25 mg for tartrate or 50 mg for succinate) 1, 3

Monitoring Algorithm

1. Check blood pressure and renal function before each dose
2. If systolic BP <90 mmHg: hold all three medications
3. If systolic BP 90-100 mmHg: hold metoprolol, consider reducing lisinopril dose by half, monitor closely
4. If creatinine >2.5 mg/dL (men) or >2.0 mg/dL (women): hold lisinopril and HCTZ
5. If K+ <3.5 mEq/L: hold HCTZ
6. If K+ >5.0 mEq/L: hold lisinopril
7. Reassess patient within 24-48 hours after holding medications

Remember that these medications are crucial for long-term outcomes in many conditions, so they should be restarted as soon as safely possible once the contraindication resolves.