What is the best approach to manage a 41-year-old female's (YOF) slightly elevated diastolic blood pressure, currently 106/90, while on EDARBI (azilsartan) 40mg/day?

Management of Elevated Diastolic Blood Pressure in a 41-Year-Old Female on Azilsartan

For a 41-year-old female with blood pressure of 106/90 mmHg on EDARBI (azilsartan) 40mg daily, the optimal approach is to increase the azilsartan dose to 80mg daily and add a thiazide/thiazide-like diuretic if target blood pressure is not achieved. 1, 2

Current Medication Assessment

• Patient is currently on azilsartan (EDARBI) 40mg daily, which is not the maximum recommended dose 2
• Current blood pressure of 106/90 mmHg indicates uncontrolled diastolic hypertension despite treatment 1
• The FDA-approved maximum dose for azilsartan is 80mg daily, which provides greater blood pressure reduction than the 40mg dose 2

Step-by-Step Management Approach

Step 1: Optimize Current Medication

• Increase azilsartan from 40mg to 80mg daily 2
• The recommended dose in adults is 80mg taken orally once daily according to FDA labeling 2
• Monitor blood pressure response for 2-4 weeks after dose adjustment 1

Step 2: If Blood Pressure Remains Uncontrolled

• Add a thiazide/thiazide-like diuretic (preferably chlorthalidone) 1, 3
• According to the International Society of Hypertension guidelines, adding a thiazide/thiazide-like diuretic is the next step in therapy for patients not achieving target blood pressure on maximum dose ARB 1, 3
• Chlorthalidone is preferred over hydrochlorothiazide due to greater efficacy and longer duration of action 4, 5

Step 3: Consider Fixed-Dose Combination

• If both medications are required, consider switching to a fixed-dose combination of azilsartan/chlorthalidone for improved adherence 1, 4
• Fixed-dose single-pill combinations are recommended to improve medication adherence 1
• Azilsartan/chlorthalidone combination has demonstrated superior blood pressure reduction compared to olmesartan/hydrochlorothiazide combinations 5

Target Blood Pressure Goals

• The target blood pressure should be <130/80 mmHg according to current guidelines 1, 3
• Aim to reduce blood pressure by at least 20/10 mmHg from baseline 1
• Blood pressure control should ideally be achieved within 3 months 1, 3

Monitoring Recommendations

• Follow up within 2-4 weeks after medication changes to assess efficacy and tolerability 1
• Monitor for potential adverse effects of increased azilsartan dose, including hypotension, dizziness, and headache 2
• If adding a diuretic, monitor electrolytes (particularly potassium) and renal function 2

Important Considerations and Caveats

• Assess for potential volume depletion before increasing dose, as patients on diuretics may be at risk for hypotension 2
• Evaluate for potential secondary causes of hypertension if blood pressure remains difficult to control despite optimal therapy 3
• If blood pressure remains uncontrolled on maximum dose azilsartan plus a thiazide diuretic, consider adding spironolactone as the next agent 1, 3
• Avoid combining azilsartan with other renin-angiotensin system blockers (such as ACE inhibitors) as this combination is not recommended 1, 2

By following this algorithmic approach, the patient's blood pressure should improve toward the target goal of <130/80 mmHg, reducing cardiovascular risk and improving long-term outcomes.