How to manage uncontrolled hypertension in a patient on Hydrochlorothiazide (HCTZ) 25 mg and Lisinopril 40 mg daily?

Management of Uncontrolled Hypertension with BP 182/70 on HCTZ and Lisinopril

Adding spironolactone 25-50 mg daily is the most effective next step for managing this patient with resistant hypertension who is already on maximum dose lisinopril and HCTZ. 1, 2

Assessment of Current Therapy

The patient's blood pressure of 182/70 mmHg while on hydrochlorothiazide 25 mg and lisinopril 40 mg daily indicates:

• Systolic hypertension remains severely uncontrolled (Stage 2)
• The patient is already on maximum dose of lisinopril (40 mg)
• The diuretic dose (HCTZ 25 mg) is appropriate
• This presentation meets criteria for resistant hypertension (BP remains >140/90 despite optimal doses of 3 drug classes or >160/100 on 2 drugs)

Next Steps in Management

1. Add Mineralocorticoid Receptor Antagonist

• Spironolactone 25-50 mg daily is the most effective next agent to add 1
• Studies show spironolactone can lower systolic BP by an additional 25 mmHg and diastolic BP by 12 mmHg when added to existing multidrug regimens including ACE inhibitors and diuretics 1
• Particularly effective for patients with resistant hypertension, regardless of plasma aldosterone or renin levels 1, 2
• Monitor potassium levels closely, especially with concurrent ACE inhibitor therapy

2. Alternative Option: Add Calcium Channel Blocker

• If spironolactone is contraindicated or not tolerated, add a dihydropyridine calcium channel blocker (e.g., amlodipine 5-10 mg daily) 2
• CCBs are particularly effective when combined with ACE inhibitors and diuretics
• Dihydropyridine CCBs are preferred to avoid excessive heart rate reduction

3. Medication Optimization Considerations

• Ensure patient is taking medications as prescribed
• Consider splitting the HCTZ dose or switching to chlorthalidone for longer duration of action
• Verify the patient is not taking medications that could interfere with BP control (NSAIDs, decongestants, etc.)

Monitoring Recommendations

• Check serum potassium and renal function within 2-4 weeks after adding spironolactone 2
• Follow-up BP check within 2-4 weeks of medication adjustment
• Continue to monitor for adverse effects:
  • Hyperkalemia (particularly with spironolactone + ACE inhibitor combination)
  • Gynecomastia (with spironolactone, more common in men)
  • Electrolyte abnormalities

Important Caveats

• Spironolactone is contraindicated if serum potassium >4.5 mmol/L or eGFR <45 ml/min/1.73m² 2
• Consider amiloride as an alternative if spironolactone causes gynecomastia 1
• Lisinopril is less effective in Black patients compared to other racial groups; ensure appropriate dosing and combination therapy 3
• Consider specialist referral if BP remains >160/100 mmHg despite optimization of three or more medications 2

Lifestyle Modifications

While optimizing medications, reinforce:

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

These medication adjustments, particularly the addition of spironolactone, should effectively address the patient's resistant hypertension while monitoring for potential adverse effects.