What is the next step for a patient with uncontrolled hypertension on valsartan (angiotensin II receptor antagonist) 80 mg who requires additional blood pressure lowering support?

Additional Blood Pressure Lowering Support for Patient on Valsartan 80 mg

For a patient with uncontrolled hypertension on valsartan 80 mg, the most effective next step is to add a thiazide diuretic or increase the valsartan dose to 160 mg, with the addition of a diuretic having a greater effect than dose increases beyond 80 mg. 1, 2

Assessment of Current Therapy

Before making changes to the regimen:

1. Confirm that the patient is adherent to the current valsartan 80 mg dose
2. Verify that lifestyle modifications are being implemented (sodium restriction, DASH diet, weight management)
3. Check for any medications that may be interfering with blood pressure control

Therapeutic Options (In Order of Preference)

Option 1: Add a Thiazide Diuretic

• Adding a thiazide diuretic has a greater effect than increasing the valsartan dose beyond 80 mg 1
• Thiazide diuretics are recommended as initial or add-on therapy for most hypertensive patients 1
• This combination (ARB + thiazide) is one of the effective combinations recommended by guidelines 1

Option 2: Increase Valsartan Dose

• Increase to valsartan 160 mg daily (FDA-approved dose range is 80-320 mg daily) 2
• The antihypertensive effect of valsartan increases predictably when doubling from 80 mg to 160 mg 3
• The tolerability profile remains comparable to placebo even at higher doses 3

Option 3: Add a Calcium Channel Blocker

• If the above options are insufficient, adding a calcium channel blocker (amlodipine 5 mg) is an effective combination 4
• The valsartan/amlodipine 80/5 mg combination has been shown to further reduce systolic/diastolic BP by 6.4/4.2 mmHg compared to valsartan 80 mg alone 4
• This combination achieved BP control rates of over 70% in patients not adequately controlled on monotherapy 4

Implementation Approach

1. Start with one change at a time - initiate or up-titrate one drug at a time using small increments until the highest tolerated or target dose is achieved 5

2. Monitor for response - the antihypertensive effect of valsartan is substantially present within 2 weeks, with maximal reduction generally attained after 4 weeks 2

3. Adjust diuretics carefully - diuretics will need to be adjusted according to volume status and may result in lower BP with overdiuresis 5

4. Target BP - aim for a target BP of <130/80 mmHg for most adults 1

Important Considerations

• Avoid certain combinations: Do not combine ACE inhibitors with ARBs or direct renin inhibitors 1
• Monitor renal function: Check serum creatinine/eGFR and potassium 1-4 weeks after starting or adjusting therapy, especially if GFR <60 mL/min/1.73m² 1
• Check for orthostatic hypotension: Measure BP in both sitting and standing positions before and after initiating new therapy 1

Special Situations

If the patient has heart failure in addition to hypertension:

• Consider using diuretics, ACE inhibitors/ARBs, β-blockers, and aldosterone receptor antagonists 5
• For patients with heart failure, target BP should be <130/80 mmHg, with consideration for lowering even further to <120/80 mmHg 5

By following this approach, you can effectively manage uncontrolled hypertension in a patient already on valsartan 80 mg while minimizing adverse effects and optimizing outcomes.