What is the next step in managing a patient with hypertension who is currently on Diovan (valsartan) 320mg and diltiazem 240mg, and has intolerance to HCTZ (hydrochlorothiazide), atenolol, and olmesartan?

Management of Hypertension in a Patient with Multiple Medication Intolerances

For a patient with hypertension who is currently on valsartan 320mg and diltiazem 240mg and cannot tolerate HCTZ, atenolol, and olmesartan, the next step should be adding spironolactone as a fourth-line agent.

Current Medication Analysis

The patient is currently on:

• Valsartan 320mg (maximum dose of an ARB)
• Diltiazem 240mg (non-dihydropyridine CCB)

Key medication intolerances:

• HCTZ (thiazide diuretic)
• Atenolol (beta-blocker)
• Olmesartan (another ARB)

Treatment Considerations

Current Regimen Issues

• The patient is on maximum dose valsartan (320mg), which is appropriate 1
• Diltiazem (non-dihydropyridine CCB) is not recommended in patients with heart failure due to negative inotropic effects 2
• The current combination lacks a diuretic component, which is typically part of triple therapy

Next Step Options

According to the 2020 International Society of Hypertension guidelines, when BP remains uncontrolled on three agents (or in this case, two agents at maximum doses with contraindications to other first-line options), the recommended next step is to add:

• Spironolactone (first choice)
• Or if not tolerated: amiloride, doxazosin, eplerenone, clonidine 2, 3

Recommended Treatment Plan

1. Add spironolactone starting at 25mg daily

   • Spironolactone is specifically recommended as the fourth-line agent in resistant hypertension 2
   • Monitor for hyperkalemia, especially with concurrent ARB therapy
   • Check baseline potassium and renal function before initiating

2. Consider replacing diltiazem with a dihydropyridine CCB

   • Non-dihydropyridine CCBs like diltiazem should be avoided in patients with heart failure 2
   • A dihydropyridine CCB (e.g., amlodipine) would be more appropriate and has better evidence for combination with ARBs 4
   • Start amlodipine at 5mg daily and titrate as needed

3. Maintain valsartan at current dose

   • The patient is already on maximum dose (320mg) 1
   • Valsartan has been shown to be effective in severe hypertension 5

Monitoring Recommendations

• Check blood pressure within 2-4 weeks after medication changes
• Monitor electrolytes (particularly potassium) and renal function within 1-2 weeks of adding spironolactone
• Target BP should be <130/80 mmHg 3
• Reassess BP control every 3 months 3

Important Considerations

• Drug interactions: Monitor for potential interactions between diltiazem and other medications, as diltiazem inhibits CYP3A4 6
• Adherence: Ensure patient is taking medications as prescribed, as non-adherence is a common cause of resistant hypertension
• Lifestyle modifications: Continue to emphasize sodium restriction and regular physical activity 2

Cautions

• Adding spironolactone requires close monitoring of potassium levels due to the increased risk of hyperkalemia when combined with an ARB
• If the patient develops signs of heart failure, the diltiazem should be discontinued immediately and replaced with a dihydropyridine CCB 2

By following this approach, you can optimize antihypertensive therapy while respecting the patient's medication intolerances and minimizing the risk of adverse effects.