What medication should be added to a patient's current regimen of losartan (angiotensin II receptor antagonist) 100mg and amlodipine (calcium channel blocker) 10mg for uncontrolled hypertension (HTN), considering their history of chronic obstructive pulmonary disease (COPD), smoking, and alcohol use, with current blood pressure of 160/90 and tachycardia?

Adding a Thiazide-like Diuretic for Uncontrolled Hypertension

A thiazide-like diuretic should be added to the current regimen of losartan 100mg and amlodipine 10mg for this patient with uncontrolled hypertension (160/90 mmHg) and tachycardia (pulse 97). 1

Assessment of Current Status

• The patient is already on maximum doses of both an ARB (losartan 100mg) and a dihydropyridine calcium channel blocker (amlodipine 10mg) 1
• Blood pressure remains uncontrolled at 160/90 mmHg, indicating the need for additional therapy 1
• Patient has relevant comorbidities including COPD, smoking, and alcohol use, which must be considered when selecting the next agent 1

Treatment Algorithm Based on Guidelines

According to the 2020 International Society of Hypertension guidelines, the recommended step-wise approach for patients with uncontrolled hypertension already on ARB and CCB is:

1. First ensure maximum doses of current medications (already achieved with losartan 100mg and amlodipine 10mg) 1
2. Add a thiazide/thiazide-like diuretic as the next step 1
3. If BP remains uncontrolled after adding a diuretic, consider adding spironolactone or alternatives such as amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Specific Recommendation

• Add a thiazide-like diuretic such as chlorthalidone 12.5-25mg daily or indapamide 1.25-2.5mg daily 1
• Thiazide-like diuretics are preferred over traditional thiazides due to their longer duration of action and evidence for better cardiovascular outcomes 1
• Research supports the efficacy of adding a thiazide diuretic to losartan for patients with inadequate BP control on losartan monotherapy 2, 3

Special Considerations for This Patient

• Beta-blockers should be used with caution due to the patient's COPD, despite the tachycardia (pulse 97), making them a less optimal choice at this stage 1
• The combination of losartan with a thiazide diuretic has shown good efficacy and tolerability in patients with high cardiovascular risk 2
• The target blood pressure should be <130/80 mmHg, with an initial goal of reducing BP by at least 20/10 mmHg 1

Monitoring Recommendations

• Assess blood pressure response within 4-6 weeks of adding the thiazide-like diuretic 1
• Monitor electrolytes (particularly potassium, sodium) and renal function 1-2 weeks after initiating the diuretic 1
• Evaluate for potential adverse effects including electrolyte disturbances, hyperuricemia, and glucose intolerance 1
• Target BP control should be achieved within 3 months; if not, consider referral to a hypertension specialist 1

Lifestyle Modifications

• Strongly encourage smoking cessation as this will improve both hypertension control and COPD management 1
• Recommend alcohol reduction or cessation, as alcohol consumption can contribute to resistant hypertension 1
• Advise sodium restriction, regular physical activity, and weight management as appropriate 1