What to do for a patient with persistent hypertension already on amlodipine (calcium channel blocker) and losartan (angiotensin II receptor antagonist)?

Management of Persistent Hypertension on Amlodipine and Losartan

For patients with persistent hypertension despite being on amlodipine and losartan, adding a thiazide-like diuretic such as indapamide 2.5 mg daily is the recommended next step. 1, 2

Assessment of Current Therapy

Before adding a third agent, ensure:

• Maximum tolerated doses of current medications are being used
• Patient adherence to medication is confirmed
• Proper BP measurement technique is being used
• Lifestyle modifications are being implemented

Step-by-Step Management Algorithm

Step 1: Optimize Current Medications

• Ensure amlodipine is at optimal dose (up to 10 mg daily)
• Ensure losartan is at optimal dose (up to 100 mg daily)
• Studies show that increasing amlodipine to 10 mg may provide better BP control than adding a diuretic in some patients 3

Step 2: Add a Thiazide-like Diuretic

• Add indapamide 2.5 mg daily 1
• Chlorthalidone 12.5-25 mg daily is an alternative option 1
• Thiazide-like diuretics are preferred over traditional thiazides due to longer half-life and proven cardiovascular event reduction 1, 2

Step 3: If BP Still Uncontrolled

• Consider adding spironolactone 25-50 mg daily as a fourth-line agent if:
  • Serum potassium <4.5 mmol/L
  • eGFR >45 ml/min/1.73m² 1, 2

Step 4: Further Options if Needed

If BP remains uncontrolled or spironolactone is contraindicated, consider:

• Amiloride
• Doxazosin
• Eplerenone
• Clonidine
• Beta-blockers 1

Monitoring Recommendations

• Check serum creatinine, eGFR, and potassium within 2-4 weeks of adding or changing doses of diuretics 2
• Monitor BP within 48-72 hours after medication adjustment 2
• Target BP should be <130/80 mmHg for most adults 2
• Annual monitoring of microalbumin/creatinine ratio to detect early kidney damage 2

Important Considerations

• Triple therapy with ARB, calcium channel blocker, and thiazide diuretic is an effective and well-tolerated combination for resistant hypertension 2
• Approximately 50% of patients diagnosed with resistant hypertension have pseudoresistance rather than true resistant hypertension 1
• If BP remains >160/100 mmHg despite ≥3 antihypertensive medications at optimal doses, consider referral to a specialist with expertise in hypertension management 1

Lifestyle Modifications

Continue to emphasize:

• Sodium restriction (<2,300 mg/day)
• DASH or Mediterranean diet
• Regular physical activity (150 minutes/week)
• Weight management
• Limited alcohol consumption
• Smoking cessation 2

By following this structured approach to managing persistent hypertension, you can systematically work through the options to achieve better blood pressure control and reduce cardiovascular risk.