What to do with a 60-year-old male patient experiencing shivering and dizziness, taking Telma (Telmisartan) 40mg for Hypertension (HTN) with a current Blood Pressure (BP) reading of 160/110mmHg?

Management of Uncontrolled Hypertension in 60-Year-Old Male with Shivering and Dizziness

This patient with uncontrolled hypertension (160/110 mmHg) despite taking Telma 40 mg requires immediate intensification of antihypertensive therapy by adding a calcium channel blocker to his current ARB regimen. 1, 2

Immediate Assessment and Management

• The patient's current BP of 160/110 mmHg classifies as Grade 2 Hypertension, requiring immediate drug treatment intensification 1, 3
• Symptoms of shivering and dizziness may indicate possible end-organ effects and require prompt evaluation 4
• Verify if the patient is taking his medication as prescribed, as non-adherence is a common cause of uncontrolled hypertension 1
• Ensure proper BP measurement technique using validated device with appropriate cuff size 1

Step-by-Step Treatment Approach

1. Increase telmisartan dose from 40 mg to 80 mg daily

   • Telmisartan 80 mg provides greater BP reduction (12-13/7-8 mmHg) compared to 40 mg (9-13/6-8 mmHg) 5
   • Maximum antihypertensive effect occurs with dosages of 40-80 mg/day 6

2. Add a dihydropyridine calcium channel blocker (DHP-CCB)

   • According to ISH guidelines, when BP remains uncontrolled on an ARB, adding a DHP-CCB is the recommended next step 1, 2
   • Amlodipine 5-10 mg daily is an appropriate choice 2
   • This combination provides complementary mechanisms of action for BP control 2

3. Optimize diuretic therapy

   • If the patient is already on hydrochlorothiazide, ensure optimal dosing 7
   • The telmisartan/HCTZ combination has demonstrated significant BP reductions in clinical trials 7

Monitoring and Follow-up

• Reassess BP within 2-4 weeks after medication changes 3
• Target BP reduction should be at least 20/10 mmHg; ideally to <130/80 mmHg 1
• BP control should be achieved within 3 months to reduce risk of end-organ damage 1, 3
• Monitor for electrolyte abnormalities, particularly potassium and sodium 2

If BP Remains Uncontrolled

• If BP remains uncontrolled after optimizing triple therapy (ARB + thiazide diuretic + DHP-CCB), add spironolactone 25-50 mg daily as the fourth agent 1, 2
• If spironolactone is not tolerated or contraindicated, alternatives include amiloride, doxazosin, eplerenone, clonidine, or a beta-blocker 1, 2
• Consider single-pill combinations to improve adherence when possible 2

Special Considerations

• Morning administration of telmisartan may provide better control of morning BP, which is particularly important for this patient presenting with symptoms 8
• Telmisartan has demonstrated efficacy in patients who failed to respond to previous antihypertensive therapy 9
• If BP remains severely elevated (≥180/120 mmHg) with evidence of acute target organ damage, consider hospitalization for close monitoring and IV therapy 4

When to Refer

• If BP remains uncontrolled despite optimal four-drug therapy, refer to a specialist with expertise in resistant hypertension 2, 3