What medication would you discontinue first in a patient with hypotension on a beta blocker, thiazide (diuretic), Angiotensin Receptor Blocker (ARB), and Sodium-Glucose Linked Transporter 2 inhibitor (SGLT2i)?

Management of Hypotension in a Patient on Multiple Antihypertensive Medications

In a patient with hypotension (BP 70/50) on multiple antihypertensive medications, the thiazide diuretic should be discontinued first to address the dangerously low blood pressure.

Assessment of Current Situation

• The patient's blood pressure of 70/50 mmHg represents significant hypotension that requires immediate intervention 1
• The current medication regimen (beta blocker, thiazide diuretic, ARB, and SGLT2i) represents aggressive antihypertensive therapy that is causing symptomatic hypotension 1
• At age 62, this level of hypotension poses significant risks including reduced organ perfusion, falls, and potential cognitive impacts 1

Medication Discontinuation Algorithm

First to Discontinue: Thiazide Diuretic

• Thiazide diuretics cause volume depletion and can significantly lower blood pressure, especially when combined with other antihypertensive medications 1
• Discontinuing the thiazide first is appropriate because:
  • It directly contributes to volume depletion 1, 2
  • Its hypotensive effects can be prolonged, especially with chlorthalidone which has a 40-60 hour half-life 3
  • Thiazide-induced hypotension can be particularly problematic when combined with RAAS inhibitors (like the ARB in this regimen) 1

Second to Consider (if BP remains low): Beta Blocker

• If blood pressure remains low after thiazide discontinuation, the beta blocker would be the next medication to reduce or discontinue 1
• Beta blockers can cause or worsen hypotension, especially when combined with other antihypertensive agents 1
• Abrupt discontinuation should be avoided; dose reduction may be preferable initially 1

Third to Consider: ARB

• ARBs can be reduced or discontinued if hypotension persists after addressing the thiazide and beta blocker 1
• They contribute to hypotension through vasodilation and reduced aldosterone effects 1

Last to Consider: SGLT2 Inhibitor

• SGLT2 inhibitors generally have the least direct effect on blood pressure among these medications 1
• They are beneficial for cardiovascular and renal outcomes and should be maintained if possible 1

Monitoring After Medication Adjustment

• Check blood pressure within 1-2 weeks after medication changes 1
• Monitor for resolution of hypotension symptoms (dizziness, lightheadedness, fatigue) 1
• Assess electrolytes, especially if the patient had been on the thiazide for an extended period 1, 4
• Gradually reintroduce medications at lower doses if needed once blood pressure has normalized 1

Important Considerations and Pitfalls

• Avoid simultaneous discontinuation of multiple antihypertensive medications, as this can lead to rebound hypertension 1
• Consider spacing remaining medications throughout the day to minimize peak hypotensive effects 1
• Assess for other causes of hypotension (dehydration, infection, adrenal insufficiency) 1
• Evaluate for orthostatic hypotension by measuring blood pressure while lying and standing 1
• Consider the patient's comorbidities when deciding which medications to continue (e.g., if heart failure is present, prioritize maintaining beta blockers) 1