What is the best alternative treatment for a 53-year-old male with hypertension (high blood pressure), currently on lisinopril (angiotensin-converting enzyme inhibitor) and metoprolol (beta blocker), who is allergic to amlodipine (calcium channel blocker)?

From the Guidelines

For a 53-year-old male with hypertension who is already on lisinopril and metoprolol with an amlodipine allergy, I recommend adding a thiazide diuretic such as hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily to his regimen, as suggested by the 2020 international society of hypertension global hypertension practice guidelines 1. This patient's blood pressure is not well controlled despite being on two antihypertensive medications, indicating the need for additional therapy. Since he cannot take amlodipine due to an allergy, a thiazide diuretic would be an appropriate third agent from a different medication class.

Key Considerations

• Thiazide diuretics work by increasing sodium and water excretion in the kidneys, reducing blood volume and therefore blood pressure.
• They complement the actions of ACE inhibitors (lisinopril) and beta-blockers (metoprolol).
• The patient should be monitored closely with follow-up within 1-2 weeks to assess the effectiveness of this regimen and potential side effects such as electrolyte abnormalities.
• Lifestyle modifications including sodium restriction, weight loss if overweight, regular physical activity, and limiting alcohol consumption should also be emphasized as important non-pharmacological approaches to help control his blood pressure.

Alternative Options

• If the patient's serum potassium is <4.5 mmol/L and whose eGFR is >45 ml/min/1.73m2, a low dose of spironolactone could be considered as a 4th line agent 1.
• Other alternatives, such as amiloride, doxazosin, eplerenone, clonidine, and beta-blockers, could be considered if spironolactone is contraindicated or not tolerated 1.

Important Notes

• The 2007 guidelines for the management of arterial hypertension 1 provide additional context, but the 2020 guidelines 1 take precedence due to their recency and relevance to current practice.

From the FDA Drug Label

Valsartan tablets are indicated for the treatment of hypertension, to lower blood pressure in adults and pediatric patients one year of age and older. Valsartan tablets may be used alone or in combination with other antihypertensive agents.

The best alternative treatment for a 53-year-old male with hypertension, currently on lisinopril and metoprolol, who is allergic to amlodipine, is valsartan, as it can be used in combination with other antihypertensive agents, such as lisinopril and metoprolol, to achieve blood pressure goals 2.

• Key benefits of valsartan include reducing the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions.
• Important consideration: Control of high blood pressure should be part of comprehensive cardiovascular risk management.

From the Research

Alternative Treatment Options

Given the patient's allergy to amlodipine, alternative treatment options for hypertension should be considered. The patient is currently on lisinopril (angiotensin-converting enzyme inhibitor) and metoprolol (beta blocker).

• Other calcium channel blockers may not be suitable due to potential cross-reactivity, as seen in a case report where a patient developed a delayed allergic reaction to amlodipine and also showed positivity to nifedipine 3.
• However, it's essential to note that cross-reactivity among calcium channel blockers has not been established, and each patient's reaction may vary.

Combination Therapies

Combination therapies can be effective in managing hypertension.

• A fixed-dose combination of amlodipine/benazepril has been shown to be effective in patients with moderate to severe hypertension, but this may not be suitable for the patient due to the amlodipine allergy 4.
• Another option could be a combination of valsartan (angiotensin II receptor blocker) with other antihypertensive agents, as valsartan has been shown to be effective in reducing blood pressure when used in combination with amlodipine or other agents 5.

Other Antihypertensive Agents

Other antihypertensive agents that could be considered as alternative treatments include:

• Angiotensin II receptor blockers (ARBs) like valsartan, which have been shown to be effective in reducing blood pressure and have a favorable side effect profile 5.
• Diuretics, which can be used in combination with other antihypertensive agents to achieve better blood pressure control.

Considerations

When selecting an alternative treatment, it's crucial to consider the patient's individual needs, medical history, and potential interactions with other medications.

• The patient's current medications, lisinopril and metoprolol, should be taken into account when choosing an alternative treatment.
• The patient's allergy to amlodipine should be considered, and potential cross-reactivity with other calcium channel blockers should be evaluated 3.