What is the appropriate treatment regimen for a patient with hypertension (high blood pressure) presenting with a blood pressure reading of 150/100 mmHg, considering initiation of therapy with Tab Telma 40 (Telmisartan 40mg)?

Treatment Regimen for Hypertension with Initial BP of 150/100 mmHg Using Telmisartan 40mg

For a patient with hypertension presenting with blood pressure of 150/100 mmHg, Telmisartan 40mg once daily is an appropriate initial treatment, with close monitoring and potential dose adjustment or combination therapy if target blood pressure is not achieved within 4 weeks.

Initial Assessment and Classification

This blood pressure reading of 150/100 mmHg falls into:

• Grade 1 hypertension (140-159/90-99 mmHg) according to British Hypertension Society 1
• Stage 2 hypertension (≥140/≥90 mmHg) according to the American College of Cardiology/American Heart Association 2
• Grade 2 hypertension (≥160/100 mmHg) according to the International Society of Hypertension 1

Treatment Approach

Starting Therapy with Telmisartan 40mg

Telmisartan 40mg once daily is an appropriate starting dose for several reasons:

• The FDA label indicates 40mg as the usual starting dose for hypertension 3
• Maximum antihypertensive effect is generally attained after 4 weeks 3
• Most of the antihypertensive effect appears within 2 weeks 3
• Clinical studies show that telmisartan 40mg can produce mean reductions in systolic/diastolic BP of up to 15.5/10.5 mmHg 4

Administration

• Telmisartan can be administered with or without food 3
• Take at the same time each day to maintain consistent 24-hour coverage 5

Monitoring and Follow-up

1. Initial follow-up: Reassess blood pressure after 2-4 weeks of therapy 1, 2
2. Laboratory monitoring:
   • Check serum creatinine, eGFR, and potassium within 2-4 weeks after initiating therapy 2
   • Continue therapy unless serum creatinine rises by more than 30% 2

Target Blood Pressure Goals

• For most adults: <130/80 mmHg 2
• For elderly patients (≥80 years): <150/90 mmHg 2
• For patients with diabetes or chronic kidney disease: <130/80 mmHg 1, 2

Treatment Escalation Algorithm

If blood pressure remains uncontrolled after 4 weeks on telmisartan 40mg:

1. Step 1: Increase telmisartan to 80mg once daily 1, 3
2. Step 2: If BP remains ≥140/90 mmHg after 2-4 weeks on maximum telmisartan dose, add a thiazide-like diuretic (preferably chlorthalidone 12.5-25mg) 1, 2, 6
3. Step 3: If BP remains uncontrolled, add a dihydropyridine calcium channel blocker 1, 2

Special Considerations

Potential Adverse Effects

• Monitor for hypotension, especially in volume-depleted patients 3
• Watch for hyperkalemia, particularly in patients with renal impairment 3
• Unlike ACE inhibitors, telmisartan has a significantly lower incidence of dry cough 4

Contraindications

• Known hypersensitivity to telmisartan 3
• Pregnancy (discontinue immediately if pregnancy detected) 3
• Do not combine with aliskiren in diabetic patients 3
• Avoid combination with ACE inhibitors 2, 3

Lifestyle Modifications

Always recommend concurrent lifestyle modifications:

• Sodium restriction (<2.3g/day)
• Regular physical activity (150 minutes/week of moderate aerobic activity)
• Weight loss if indicated
• DASH or Mediterranean diet
• Alcohol limitation
• Smoking cessation 2

Long-term Benefits

Beyond blood pressure control, telmisartan offers additional benefits:

• Long elimination half-life providing 24-hour coverage, including early morning hours 7, 8
• Potential favorable effects on insulin resistance, lipid levels, and left ventricular hypertrophy 5
• Cardiovascular protective effects similar to ACE inhibitors but with better tolerability 8

When to Consider Referral

Consider referral to a specialist if:

• BP remains ≥160/100 mmHg despite treatment with ≥3 drugs 1
• Multiple drug intolerances occur 1
• Secondary causes of hypertension are suspected 1

Telmisartan 40mg is an effective starting dose for a patient with BP of 150/100 mmHg, with clear pathways for dose adjustment and combination therapy if needed to achieve target blood pressure.