How would you adjust the prescription for a 58-year-old African-American male with uncontrolled hypertension and hyperlipidemia who is currently taking amlodipine (calcium channel blocker) 5 mg daily?

Hypertension Management in a 58-Year-Old African-American Male

For a 58-year-old African-American male with uncontrolled hypertension and hyperlipidemia on amlodipine 5 mg daily, the most appropriate adjustment would be to increase amlodipine to 10 mg daily and add a thiazide diuretic.

Assessment of Current Treatment

The patient's current regimen of amlodipine 5 mg daily is inadequate for blood pressure control. This is particularly important to address given:

• African-American ethnicity (typically more responsive to calcium channel blockers and diuretics)
• Middle age (58 years)
• Multiple cardiovascular risk factors (hypertension and hyperlipidemia)

Recommended Treatment Adjustments

Step 1: Optimize Current Medication

• Increase amlodipine from 5 mg to 10 mg daily
  • The FDA-approved dosing for amlodipine allows for titration up to 10 mg daily 1
  • Increasing amlodipine from 5 mg to 10 mg can produce additional significant BP reduction of approximately 12.5 mmHg systolic and 6.0 mmHg diastolic 2

Step 2: Add a Second Agent

• Add a thiazide or thiazide-like diuretic
  • For African-American patients, a CCB + thiazide diuretic combination is particularly effective 3
  • This combination provides complementary mechanisms of action

Alternative Option if Above Not Tolerated

• Consider an ARB instead of a thiazide diuretic as the second agent
  • The combination of CCB + ARB is effective and well-tolerated 3
  • Avoid ACE inhibitors initially as they may be less effective as monotherapy in African-American patients

Rationale for Recommendation

1. Evidence-based approach: The European Society of Cardiology recommends combination therapy for most patients with confirmed hypertension, particularly a CCB + thiazide diuretic combination for Black patients 4, 3

2. Optimized dosing: Increasing amlodipine to 10 mg has been shown to provide additional BP reduction without significant increase in adverse effects 2

3. Race-specific considerations: African-American patients typically respond better to calcium channel blockers and diuretics than to ACE inhibitors or ARBs as monotherapy 3

4. Simplified regimen: Consider a single-pill combination when available to improve adherence 3

Monitoring and Follow-up

• Reassess blood pressure within 2-4 weeks after medication adjustment 3
• Monitor for potential side effects:
  • Peripheral edema (common with higher doses of amlodipine)
  • Electrolyte abnormalities (if diuretic added)
  • Renal function (especially if adding an ARB later)

Additional Considerations

Lipid Management

• Given the patient's hyperlipidemia, consider statin therapy if not already prescribed
• Target LDL-C goal of <1.4 mmol/L (55 mg/dL) and >50% reduction from baseline 3

Lifestyle Modifications

• Emphasize sodium restriction (<2,300 mg/day)
• Recommend DASH or Mediterranean diet
• Encourage regular physical activity (150 minutes/week)
• Advise weight management if applicable
• Recommend limiting alcohol consumption
• Encourage smoking cessation if applicable

Potential Pitfalls to Avoid

1. Inadequate dosing: Don't hesitate to increase amlodipine to 10 mg as studies show significant additional benefit 5, 2

2. Inappropriate combinations: Avoid combining two RAS blockers (ACE inhibitor + ARB) if therapy needs to be escalated further 4, 3

3. Delayed follow-up: Ensure timely reassessment of blood pressure after medication changes 3

4. Ignoring race-specific responses: African-American patients typically respond better to CCBs and diuretics 3