What should be added to a 34-year-old female's regimen of nifedipine (Procardia) 60 ER for uncontrolled hypertension with systolic blood pressure in the 140s?

Adding a Thiazide/Thiazide-like Diuretic to Nifedipine for Uncontrolled Hypertension

For a 34-year-old female on nifedipine 60 ER with systolic blood pressure still in the 140s, a thiazide/thiazide-like diuretic should be added as the next step in therapy. 1

Rationale for Adding a Thiazide/Thiazide-like Diuretic

• The patient is currently on a dihydropyridine calcium channel blocker (DHP-CCB) at maximum dose but has not achieved target blood pressure 1
• According to the 2020 International Society of Hypertension (ISH) guidelines, the next step after maximizing DHP-CCB dose is to add a thiazide/thiazide-like diuretic 1
• This follows the recommended stepwise approach for hypertension management, particularly for patients who have not achieved target blood pressure on monotherapy 1

Treatment Algorithm Based on Race

For Non-Black Patients (as in this case):

1. Start with low dose ACEI/ARB (Step 1)
2. Increase to full dose (Step 2)
3. Add thiazide/thiazide-like diuretic (Step 3)
4. Add spironolactone or alternatives if not tolerated (Step 4) 1

For Black Patients:

1. Start with low dose ARB + DHP-CCB or DHP-CCB + thiazide/thiazide-like diuretic (Step 1)
2. Increase to full dose (Step 2)
3. Add diuretic or ARB/ACEI (Step 3)
4. Add spironolactone or alternatives if not tolerated (Step 4) 1

Clinical Considerations

• The patient is already on nifedipine 60 ER (a DHP-CCB) at maximum dose but has not achieved target blood pressure 1
• Target blood pressure should be <130/80 mmHg according to current guidelines 1
• The systolic blood pressure in the 140s indicates Grade 1 Hypertension (140-159/90-99 mmHg) requiring medication adjustment 1
• Adding a thiazide/thiazide-like diuretic provides complementary mechanism of action to the calcium channel blocker 1

Monitoring Recommendations

• Blood pressure should be monitored to achieve target within 3 months 1
• Target reduction should be at least 20/10 mmHg with an ideal goal of <130/80 mmHg 1
• Check for medication adherence if blood pressure remains uncontrolled 1
• Consider home or ambulatory blood pressure monitoring to confirm office readings 1

Important Caveats

• If blood pressure remains uncontrolled after adding a thiazide/thiazide-like diuretic, the next step would be to add spironolactone (if tolerated) or alternatives like amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1
• Combination therapy has been shown to provide better antihypertensive effect than increasing the dose of a single agent 2
• If blood pressure remains uncontrolled despite optimal medical therapy, refer to a provider with expertise in hypertension management 1
• Always assess for potential secondary causes of hypertension, particularly in younger patients with resistant hypertension 1