What is the recommended treatment for an 82-year-old female patient with uncontrolled hypertension (elevated blood pressure) and hyperglycemia (high blood sugar), currently on losartan (angiotensin II receptor antagonist) 25mg and receiving 5 units of insulin (hypoglycemic agent) at bedtime?

Management of Uncontrolled Hypertension and Hyperglycemia in an Elderly Patient

The patient requires immediate intensification of both antihypertensive and antidiabetic therapy, with addition of a calcium channel blocker for hypertension and rapid-acting insulin for hyperglycemia. 1

Hypertension Management

Current Status and Immediate Intervention

• BP 185/88 mmHg indicates Stage 2 Hypertension requiring urgent attention
• Current regimen: Losartan 25mg daily (last dose 9 AM)
• Recommended intervention:
  1. Add a calcium channel blocker (CCB) immediately as this patient has a BP ≥160/100 mmHg requiring dual therapy 1
  2. Increase losartan to 50mg daily (ARBs are preferred for patients with diabetes) 1
  3. Consider adding a thiazide-like diuretic if BP remains uncontrolled after CCB addition 1

Monitoring

• Recheck BP within 48-72 hours after medication adjustment 1
• Monitor renal function and electrolytes within 2-4 weeks of therapy changes, especially with ARB dose increase 1
• Target BP for this elderly patient should be <130/80 mmHg 1

Hyperglycemia Management

Current Status and Immediate Intervention

• Blood glucose of 423 mg/dL indicates severe hyperglycemia requiring immediate treatment
• Current regimen: Only 5 units of insulin at bedtime (grossly inadequate)
• Recommended intervention:
  1. Administer rapid-acting insulin immediately using correction scale (typically 1 unit per 50 mg/dL above 150 mg/dL)
  2. Initiate basal-bolus insulin regimen with:
     • Basal insulin: 0.2 units/kg/day
     • Prandial insulin: 0.1-0.2 units/kg/day divided before meals
  3. Increase bedtime insulin dose significantly (current 5 units is insufficient)
  4. Consider adding oral antidiabetic medication appropriate for elderly patients

Monitoring

• Check blood glucose every 4-6 hours until stabilized
• Monitor for hypoglycemia, especially with increased insulin dosing
• Be cautious with losartan as it may attenuate hypoglycemic symptoms 2

Important Considerations

Medication Interactions

• Losartan may mask hypoglycemic symptoms, requiring more vigilant glucose monitoring 2
• When combining losartan with a diuretic, monitor for electrolyte imbalances 1

Age-Specific Concerns

• At 82 years old, medication adjustments should be made gradually to prevent adverse effects
• Avoid aggressive BP lowering; aim for a reduction of 20-25% initially 3
• Monitor for orthostatic hypotension with antihypertensive therapy

Follow-up Plan

• Arrange follow-up within 1 week to assess response to therapy
• Consider home BP and glucose monitoring
• Evaluate for target organ damage from prolonged hypertension
• Annual monitoring of microalbumin/creatinine ratio to detect early kidney damage 1

Lifestyle Modifications

• Sodium restriction (<2,300 mg/day)
• Mediterranean or DASH diet
• Appropriate physical activity as tolerated
• Weight management if applicable 1