What can be added as a second blood pressure medicine for a person taking Diovan HCT (valsartan + hydrochlorothiazide)?

Adding a Second Blood Pressure Medication to Diovan HCT

For patients already taking Diovan HCT (valsartan + hydrochlorothiazide) who need additional blood pressure control, a calcium channel blocker (CCB) is the most appropriate next agent to add to the regimen. 1

Rationale for Adding a Calcium Channel Blocker

• Diovan HCT already contains two first-line antihypertensive agents: an angiotensin receptor blocker (valsartan) and a thiazide diuretic (hydrochlorothiazide), making a calcium channel blocker the logical next choice 1
• The 2020 International Society of Hypertension guidelines recommend a three-drug combination of RAS blocker (ARB/ACEI) + dihydropyridine CCB + thiazide/thiazide-like diuretic as the preferred triple therapy 1
• This three-drug combination provides complementary mechanisms of action, targeting different pathways of blood pressure regulation 1
• Fixed-dose single-pill combinations are recommended whenever possible to improve adherence 1

Specific Recommendations Based on Patient Demographics

For Non-Black Patients:

• Add a dihydropyridine calcium channel blocker (such as amlodipine) 1
• If CCB is contraindicated or not tolerated, consider adding spironolactone as the fourth agent 1

For Black Patients:

• A dihydropyridine CCB is particularly effective and should be added if not already part of the regimen 1
• The combination of ARB + diuretic + CCB is especially effective in this population 1

Dosing Considerations

• Start with a low dose of the added CCB and titrate upward as needed 1
• Consider the timing of medication administration to optimize 24-hour blood pressure control 2
• Once-daily dosing is preferred to improve adherence 1

Alternative Options if CCB is Not Suitable

If a CCB cannot be used, consider the following alternatives in order of preference:

1. Spironolactone (particularly effective in resistant hypertension) 1
2. Amiloride (if spironolactone is not tolerated) 1
3. Alpha-blockers such as doxazosin (though with caution due to increased risk of heart failure) 1
4. Beta-blockers (particularly if there are compelling indications such as coronary artery disease, post-MI, or heart failure) 1

Important Cautions

• Avoid combining ACE inhibitors with ARBs (valsartan) as this combination increases adverse effects without additional benefit 1
• Beta-blockers should be used with caution unless there are specific indications (coronary disease, heart failure, post-MI) 1
• Monitor for electrolyte abnormalities, particularly when using multiple agents that affect potassium levels 1
• Be cautious with non-dihydropyridine CCBs (diltiazem, verapamil) in patients with heart failure 1

Blood Pressure Targets

• For most adults, target blood pressure should be <130/80 mmHg 1
• In elderly or frail patients, targets may be individualized, but aim to reduce systolic BP by at least 20/10 mmHg 1
• Monitor BP control and aim to achieve target within 3 months of treatment adjustment 1

Monitoring Recommendations

• Evaluate BP response within 2-4 weeks of adding the new medication 1
• Monitor for potential adverse effects specific to the combination therapy 1
• Consider home BP monitoring to assess 24-hour control and treatment adherence 1