What is the next step for a patient with uncontrolled Hypertension (HTN) taking lisinopril (Angiotensin-Converting Enzyme Inhibitor)/hydrochlorothiazide (HCTZ) (Thiazide Diuretic) 20/25 mg?

Management of Uncontrolled Hypertension in a Patient on Lisinopril/HCTZ 20/25 mg

For a patient with uncontrolled hypertension on lisinopril/HCTZ 20/25 mg, the next step should be adding a calcium channel blocker (CCB), preferably a dihydropyridine (DHP) type, to the current regimen. 1

Assessment Before Medication Change

• Verify medication adherence and proper BP measurement technique to rule out pseudoresistance 1
• Check for substances that may interfere with BP control (NSAIDs, stimulants, etc.) 1
• Consider home or ambulatory BP monitoring to confirm uncontrolled hypertension 1

Medication Management Algorithm

Step 1: Add a Calcium Channel Blocker

• Add a dihydropyridine calcium channel blocker (DHP-CCB) to the current regimen 1
• This follows the guideline-recommended progression for non-black patients who have already been on an ACE inhibitor and thiazide diuretic 1

Step 2: If BP Remains Uncontrolled After Adding CCB

• Add spironolactone (start with 12.5-25 mg daily) as a fourth agent 1
• Monitor potassium levels closely, especially with concurrent ACE inhibitor use 1

Step 3: If Spironolactone is Not Tolerated or Contraindicated

• Alternative fourth-line options include:
  • Amiloride 1
  • Doxazosin 1
  • Eplerenone 1
  • Clonidine 1
  • Beta-blocker 1

Special Considerations

For Black Patients

• If the patient is black, consider optimizing the CCB and diuretic doses before adding other agents 1
• ARBs may be preferred over ACE inhibitors in black patients 1

Resistant Hypertension

• If BP remains uncontrolled on ≥3 medications (including a diuretic), consider:
  • Screening for secondary causes of hypertension 1
  • Referral to a hypertension specialist 1

Monitoring and Follow-up

• Target BP should be <130/80 mmHg for most patients 1
• Reassess BP control within 3 months of medication change 1
• Monitor for adverse effects, particularly electrolyte abnormalities with diuretic therapy 1

Common Pitfalls to Avoid

• Avoid using same-class combinations (e.g., adding another ACE inhibitor or ARB) 1
• Don't increase lisinopril beyond 40 mg daily as higher doses provide minimal additional benefit 2
• Don't overlook the importance of lifestyle modifications (sodium restriction, weight loss, physical activity) alongside medication adjustments 1, 3

Adding a DHP-CCB represents the most evidence-based next step for this patient with uncontrolled hypertension already on an ACE inhibitor and thiazide diuretic combination 1.