What is the next best step for a hypertensive patient on losartan 50 mg bd with a history of ankle edema from amlodipine and a blood pressure of 179/100 mmHg?

Management of Uncontrolled Hypertension in a Patient with History of Ankle Edema

The next best step for this hypertensive patient is to add a thiazide diuretic (chlorthalidone 12.5-25 mg daily) to the current losartan regimen while adjusting the losartan dosing to once daily.

Current Medication Assessment

The patient is currently on:

• Losartan 50 mg twice daily (total 100 mg/day)
• Voglibose 0.3 mg once daily (for glycemic control)
• History of ankle edema with amlodipine
• Current BP: 179/100 mmHg (Stage 2 hypertension)

Recommended Medication Adjustments

1. Optimize ARB Dosing

• Consolidate losartan dosing: Change from 50 mg twice daily to 100 mg once daily
  • The ACC/AHA guidelines indicate losartan's recommended dosing is 50-100 mg daily, which can be given once or twice daily 1
  • Once-daily dosing may improve adherence while maintaining efficacy

2. Add Thiazide Diuretic

• Add chlorthalidone 12.5 mg daily
  • Chlorthalidone is preferred over hydrochlorothiazide due to its longer half-life and proven cardiovascular disease reduction 1
  • This combination provides complementary mechanisms of action for BP control

3. Avoid Calcium Channel Blockers

• Do not add amlodipine due to patient's history of ankle edema with this medication
  • Dihydropyridine CCBs are associated with dose-related pedal edema, more common in women 1

Rationale for This Approach

1. Inadequate BP Control: The current BP of 179/100 mmHg indicates stage 2 hypertension requiring prompt intensification of therapy 1

2. Optimizing Current Therapy:

   • The patient is already on losartan but at a suboptimal regimen (twice daily instead of the more convenient once daily at the same total dose) 2
   • FDA labeling for losartan indicates that once-daily dosing at 100 mg provides effective 24-hour blood pressure control 2

3. Combination Therapy Benefits:

   • The ACC/AHA guidelines recommend combination therapy with two agents of different classes for stage 2 hypertension 1
   • The combination of an ARB with a thiazide diuretic has synergistic effects on BP reduction 2
   • Adding hydrochlorothiazide 12.5 mg to losartan 50 mg has been shown to produce placebo-adjusted BP reductions of 15.5/9.2 mmHg 2

4. Avoiding Adverse Effects:

   • Patient has history of ankle edema with amlodipine, making other CCBs less desirable 3
   • Losartan with thiazide diuretic combination is generally well-tolerated 4, 3

Follow-up Plan

1. Short-term follow-up: Reassess BP within 2-4 weeks after medication changes 5

2. Laboratory monitoring:

   • Check serum potassium and renal function within 1-2 weeks of adding the thiazide diuretic
   • Monitor for hyponatremia, hypokalemia, and changes in uric acid levels 1

3. Dose adjustment:

   • If BP goal is not achieved after 4 weeks, consider increasing chlorthalidone to 25 mg daily
   • For resistant hypertension, consider adding a mineralocorticoid receptor antagonist (spironolactone) 5

Additional Considerations

• Lifestyle modifications: Reinforce dietary changes (DASH diet, sodium restriction), regular exercise, and weight management 5

• Medication timing: Consider administering the once-daily losartan in the morning and monitoring for any orthostatic symptoms

• Diabetes management: Continue voglibose 0.3 mg daily and monitor glycemic control, as thiazide diuretics can affect glucose levels

This approach provides a practical, evidence-based strategy to control the patient's blood pressure while avoiding medications that previously caused adverse effects.