Should I increase the dose of lisinopril (angiotensin-converting enzyme inhibitor) for a patient with uncontrolled hypertension?

Management of Hypertension in a 70-Year-Old Female on Lisinopril

Yes, you should increase the lisinopril dose as the patient's blood pressure readings of 130/90,132/88 in office and 140/90 at home indicate uncontrolled hypertension requiring dose escalation according to current guidelines. 1

Current Status Assessment

• Patient is a 70-year-old female currently on lisinopril 5 mg daily 2
• Office BP readings: 130/90 mmHg and 132/88 mmHg 1
• Home BP readings: approximately 140/90 mmHg 1
• These readings exceed the target BP of <130/80 mmHg recommended for this age group 1

Rationale for Dose Increase

• The 2020 International Society of Hypertension guidelines recommend increasing ACE inhibitor dose to full dose before adding additional agents in non-black patients 1
• For patients aged 50-80 years with persistent BP elevation, prompt medication adjustment is indicated rather than extended periods of lifestyle modification alone 1
• The patient's current BP readings indicate Grade 1 Hypertension (140-159/90-99 mmHg), which requires medication adjustment 1
• The FDA label for lisinopril indicates that dose titration is appropriate when BP is not adequately controlled on the current dose 2

Recommended Approach

1. Increase lisinopril from 5 mg to 10 mg daily 1, 2

   • This follows the guideline recommendation to increase to full dose of ACE inhibitor before adding additional agents 1
   • Monitor BP response over the next 4 weeks 1

2. If BP remains uncontrolled after 4 weeks on increased dose:

   • Consider further increasing lisinopril up to 20 mg daily 1, 2
   • Studies in elderly hypertensive patients have shown good tolerability with lisinopril doses up to 20 mg daily 3

3. If BP remains uncontrolled on maximum tolerated lisinopril dose:

   • Add a thiazide/thiazide-like diuretic as the next step 1
   • This combination has shown superior efficacy compared to monotherapy, with mean BP reductions of 23.9/18.2 mmHg in combination therapy versus 16.6/12.5 mmHg with lisinopril alone 4

Special Considerations for Elderly Patients

• Target BP for this 70-year-old patient should be <130/80 mmHg, but individualize based on frailty status 1

• Monitor for potential adverse effects more closely in elderly patients, including:

  • Postural hypotension 3
  • Changes in renal function 5
  • Electrolyte disturbances 6

• Lisinopril has been shown to be effective and well-tolerated in elderly hypertensive patients, with studies demonstrating significant BP reduction without significant alterations in heart rate or occurrence of postural hypotension 3

Monitoring Recommendations

• Recheck BP within 4 weeks of dose adjustment 1
• Assess for side effects: dizziness, cough, changes in renal function 6
• Aim to achieve target BP within 3 months of treatment initiation 1
• Consider home BP monitoring to guide therapy, with target home BP <135/85 mmHg 1