Should I restart amlodipine and lisinopril at the previous dose for a patient with hypertension who has been off the medications for 6 months?

Management of Severe Hypertension After Medication Non-Adherence

For a patient with BP 160/110 mmHg after 6 months off medications, restart both amlodipine 10 mg and lisinopril 30 mg at their previous full doses immediately.

Rationale for Immediate Full-Dose Restart

The patient's blood pressure of 160/110 mmHg represents stage 2 hypertension with significant cardiovascular risk. According to the 2017 ACC/AHA guidelines, patients with stage 2 hypertension (≥160/100 mmHg) should be promptly treated with antihypertensive medications 1.

The guidelines specifically state:

• For adults with a very high average BP (e.g., SBP ≥180 mm Hg or DBP ≥110 mmHg), evaluation followed by prompt antihypertensive drug treatment is recommended 1
• The patient's current DBP of 110 mmHg meets this threshold, warranting immediate intervention

Medication Selection and Dosing

• Previous medications were appropriate: The combination of an ACE inhibitor (lisinopril) and calcium channel blocker (amlodipine) is a guideline-recommended combination for hypertension management
• Full dose restart is justified because:
  • The patient was previously tolerating these doses
  • The current BP is significantly elevated, requiring effective control
  • For patients with BP ≥160/100 mmHg, prompt treatment with full therapeutic doses is recommended 1
  • The FDA label for lisinopril does not indicate a need for dose reduction after a period of non-use 2

Monitoring After Restart

After restarting medications:

• Schedule follow-up within 2-4 weeks to assess BP response and medication tolerance 3
• Check serum creatinine, eGFR, and potassium within 2-4 weeks of restarting therapy, especially with the ACE inhibitor 3, 2
• If BP remains elevated despite restarting both medications, consider adding a thiazide diuretic 4

Alternative Approaches (Not Recommended)

While some might consider a step-wise approach (starting with lower doses and titrating up), this is not optimal for this patient because:

• The patient has severe hypertension requiring immediate effective control
• The patient previously tolerated these doses without documented adverse effects
• Starting with lower doses would delay achieving BP control, unnecessarily prolonging cardiovascular risk

Addressing Medication Adherence

To improve future adherence:

• Discuss barriers that led to medication discontinuation
• Consider once-daily dosing regimens where possible
• Educate on the importance of continuous therapy and risks of uncontrolled hypertension
• Consider fixed-dose combinations to simplify the regimen 3

Target Blood Pressure

The goal is to reduce BP to <130/80 mmHg for optimal cardiovascular protection, with a minimum acceptable level of <140/90 mmHg 3.