What is the next best antihypertensive medication for a 73-year-old female with a history of adverse reactions to Hydrochlorothiazide (HCTZ) and Amlodipine, currently taking Valsartan (Diovan) 320 mg daily, with blood pressure in the 150s/90s range and palpitations?

Next Antihypertensive Option for 73-Year-Old Female with Adverse Reactions to HCTZ and Amlodipine

A beta-blocker, specifically carvedilol, is the most appropriate next antihypertensive medication for this 73-year-old female patient with uncontrolled hypertension and palpitations who has experienced adverse reactions to HCTZ and amlodipine.

Patient Assessment

• 73-year-old female with BP 150s/90s (Stage 2 hypertension)
• Currently on valsartan (Diovan) 320 mg daily (maximum dose)
• History of adverse reactions:
  • Redness with HCTZ
  • Swelling with amlodipine
• Reports palpitations, though heart rate is normal
• No history of asthma or COPD

Medication Selection Rationale

Why Beta-Blockers Are Appropriate

1. Addresses Both Hypertension and Palpitations: Beta-blockers are effective for treating both hypertension and palpitations 1
2. Complementary Mechanism: Beta-blockers work through a different mechanism than ARBs, providing additive blood pressure lowering effects 1
3. Avoids Known Adverse Reactions: The patient has already shown intolerance to both a thiazide diuretic (HCTZ) and a calcium channel blocker (amlodipine) 1

Specific Beta-Blocker Selection

Among beta-blockers, carvedilol is the optimal choice because:

• It has combined alpha- and beta-blocking properties, providing more effective BP reduction 1
• It has been shown to improve outcomes in cardiovascular disease 1
• Starting dose of 12.5 mg twice daily, can be titrated up to 50 mg daily in divided doses 1
• Less likely to cause metabolic disturbances compared to other beta-blockers 1

Alternative Options to Consider

If Beta-Blockers Are Contraindicated:

1. Non-dihydropyridine CCBs:

   • Diltiazem ER (120-360 mg daily) or verapamil SR (120-360 mg daily) 1
   • Caution: Monitor for bradycardia, especially in an elderly patient with palpitations 1

2. Aldosterone Receptor Antagonists:

   • Spironolactone (25-100 mg daily) 1
   • Particularly effective in resistant hypertension 1
   • Monitor for hyperkalemia, especially when combined with an ARB 1

3. Loop Diuretics:

   • Furosemide (20-80 mg twice daily) or torsemide (5-10 mg daily) 1
   • Different mechanism than thiazides, may avoid similar adverse reactions 1

Implementation Plan

1. Initial Dosing:

   • Start carvedilol at 12.5 mg twice daily 1
   • Lower starting dose (6.25 mg twice daily) may be considered given patient's age

2. Monitoring:

   • Check BP and heart rate within 2-4 weeks after initiation 2
   • Monitor for potential side effects: fatigue, dizziness, bradycardia
   • Assess for improvement in palpitations

3. Dose Titration:

   • If BP remains elevated and medication is well tolerated, increase dose gradually
   • Maximum dose: 50 mg daily in divided doses 1

Important Considerations

Potential Adverse Effects

• Bradycardia, fatigue, dizziness, and hypotension are common side effects of beta-blockers 1
• Risk of masking hypoglycemia symptoms if patient develops diabetes
• Avoid abrupt discontinuation to prevent rebound hypertension 1

Drug Interactions

• Valsartan can be safely combined with beta-blockers 3
• The combination provides complementary mechanisms of action for BP control

Conclusion

Carvedilol is the most appropriate next-step medication for this 73-year-old female patient with uncontrolled hypertension and palpitations who has experienced adverse reactions to both HCTZ and amlodipine. This choice addresses both her hypertension and palpitations while avoiding medications that have previously caused adverse reactions.