What adjustments should be made to the antihypertensive regimen for a patient with uncontrolled hypertension taking losartan 100mg, metoprolol 100mg bid, and norvasc 10mg daily with a blood pressure of 180/90?

Management of Uncontrolled Hypertension with BP 180/90 on Triple Therapy

The patient with BP 180/90 on maximum doses of losartan, metoprolol, and amlodipine should have a thiazide-like diuretic added to the regimen, as this is the recommended next step for resistant hypertension. 1

Current Medication Analysis

• Losartan 100mg daily (maximum FDA-approved dose) 2
• Metoprolol 100mg twice daily (beta-blocker)
• Amlodipine 10mg daily (maximum dose of calcium channel blocker)

Assessment of Hypertension

• BP 180/90 indicates Stage 2 hypertension and is significantly above the recommended target of 120-129/70-79 mmHg 1
• The patient is already on three antihypertensive medications at optimal doses, meeting the definition of resistant hypertension (BP ≥130/80 mmHg despite adherence to ≥3 antihypertensive medications at optimal doses, including a diuretic, or requiring ≥4 antihypertensive medications for control) 1
• Current regimen includes an ARB, CCB, and beta-blocker, but lacks a diuretic component

Recommended Medication Adjustment

1. Add a thiazide-like diuretic:

   • Add hydrochlorothiazide 12.5mg daily, with potential to increase to 25mg if needed 1
   • The combination of losartan with hydrochlorothiazide has demonstrated significant additional BP reductions of 15.5/9.2 mmHg in clinical trials 2

2. Consider fixed-dose combination:

   • A fixed-dose combination of losartan/HCTZ may improve adherence 1
   • Losartan/HCTZ combinations (50/12.5mg or 100/25mg) have shown efficacy in severe hypertension 3

Rationale for Adding a Diuretic

• Guidelines specifically recommend a thiazide-like diuretic as a third agent if BP remains uncontrolled on ARB + CCB combination 1
• The combination of losartan with hydrochlorothiazide has demonstrated superior efficacy compared to increasing losartan dose alone 4
• In patients with severe hypertension, losartan/HCTZ combination has shown significant BP reductions (25.4/18.4 mmHg) 3

Monitoring Recommendations

1. Recheck BP in 2-4 weeks after adding the diuretic
2. Monitor electrolytes, particularly potassium and sodium, within 1-2 weeks of starting the diuretic
3. Assess renal function
4. Consider home BP monitoring to confirm uncontrolled status and evaluate response to therapy 1

Important Considerations

• Ensure patient adherence to current medication regimen before adding another agent
• Reinforce lifestyle modifications that can further reduce BP:
  • Sodium restriction (<1500 mg/day): 1-3 mmHg SBP reduction
  • DASH diet: ~5 mmHg SBP reduction
  • Weight loss: ~1 mmHg SBP reduction per 1 kg weight loss
  • Physical activity: 90-150 minutes/week 1

Alternative Approaches if Diuretic Addition Fails

1. Consider increasing hydrochlorothiazide to 25mg if initial response is inadequate
2. Consider switching to a more potent thiazide-like diuretic such as chlorthalidone or indapamide
3. Consider referral to a hypertension specialist if BP remains uncontrolled after adding a diuretic at optimal dose

Adding a thiazide diuretic represents the most evidence-based next step for this patient with resistant hypertension who is already on maximum doses of three different classes of antihypertensive medications.