What additional anti-hypertensive medications can be given to a dialysis patient already on amlodipine (calcium channel blocker) 10 mg once a day, valsartan (angiotensin II receptor antagonist) plus hydrochlorothiazide (HCTZ, diuretic) 320/25 mg, terazosin (alpha-blocker) 5 mg, and carvedilol (beta-blocker) 25 mg twice a day?

Additional Antihypertensive Options for Dialysis Patients

For a dialysis patient already on multiple antihypertensive medications, adding a loop diuretic such as furosemide or torsemide would be the most appropriate next step, as these are preferred in patients with end-stage renal disease. 1, 2

Current Medication Analysis

The patient is currently on:

• Amlodipine 10 mg daily (calcium channel blocker)
• Valsartan/HCTZ 320/25 mg (ARB + thiazide diuretic)
• Terazosin 5 mg (alpha-blocker)
• Carvedilol 25 mg twice daily (combined alpha and beta-blocker)

This regimen already includes multiple drug classes but has several issues:

• Hydrochlorothiazide is minimally effective in dialysis patients due to severely reduced GFR 2
• The patient is already on maximum doses of amlodipine and valsartan 1
• The regimen includes both an alpha-blocker (terazosin) and a combined alpha/beta-blocker (carvedilol) 1

Recommended Additional Medications

First-line option:

• Loop diuretic (furosemide 20-80 mg twice daily or torsemide 5-10 mg once daily) 1, 2
  • Loop diuretics are preferred over thiazides in patients with severe CKD (GFR <30 mL/min) 1
  • They can help manage volume status even in dialysis patients 2

Alternative options:

1. Mineralocorticoid receptor antagonist (spironolactone 25 mg daily) 1

   • Preferred agent in resistant hypertension 1
   • Start at 12.5-25 mg once daily, maximum 50 mg daily 1
   • Monitor potassium levels closely 1

2. Non-dihydropyridine calcium channel blocker (diltiazem ER 120-360 mg daily) 1, 3

   • Different mechanism than amlodipine (already in regimen)
   • Avoid if patient has heart failure with reduced ejection fraction 1
   • Monitor for bradycardia when used with beta-blockers 1

3. Direct vasodilator (hydralazine 25-50 mg three or four times daily) 2, 3

   • Effective for blood pressure control in dialysis patients 2
   • Can be used in combination with current medications 3

Medication Administration Considerations

• For patients with compliance issues, consider medications that can be administered post-dialysis under supervision 2, 3
• ACE inhibitors and ARBs with predominant renal elimination (like lisinopril) can be given thrice weekly after dialysis 2
• Transdermal clonidine (0.1 mg patch weekly) may benefit non-compliant patients 2

Important Monitoring Parameters

• Monitor for hyperkalemia, especially with mineralocorticoid receptor antagonists 1
• Assess volume status regularly to prevent hypotension during dialysis 2
• Monitor heart rate if adding non-dihydropyridine CCBs to beta-blocker therapy 1
• Evaluate for orthostatic hypotension due to multiple vasodilating agents 3

Common Pitfalls to Avoid

• Avoid increasing hydrochlorothiazide dose as it has minimal efficacy in dialysis patients 2
• Be cautious with ACE inhibitors due to risk of anaphylactoid reactions with certain dialysis membranes (particularly AN69) 2
• Avoid medications requiring multiple daily doses when possible to improve compliance 3
• Be aware that non-selective beta-blockers can increase serum potassium, particularly during fasting or exercise 2

Medication Adjustment Strategy

1. First, consider removing hydrochlorothiazide as it has minimal efficacy in dialysis patients 2
2. Add a loop diuretic as the first-line additional agent 1, 2
3. If blood pressure remains uncontrolled, add spironolactone as the next agent 1
4. Consider timing of medications (preferably at night) to control nocturnal blood pressure and minimize intradialytic hypotension 3