What additional medication can be added to metoprolol (beta blocker) for a patient with uncontrolled hypertension (blood pressure in the 140s/80s)?

Adding a Thiazide-like Diuretic to Metoprolol for Uncontrolled Hypertension

For a patient with uncontrolled hypertension (BP 140s/80s) on metoprolol, adding a thiazide-like diuretic such as chlorthalidone 12.5-25mg daily is the recommended next step to achieve better blood pressure control. 1, 2

Rationale for Adding a Thiazide-like Diuretic

• Current guidelines recommend a step-wise approach for managing uncontrolled hypertension, with thiazide/thiazide-like diuretics being a preferred addition to beta-blockers 1
• The patient's blood pressure in the 140s/80s exceeds the target of <140/90 mmHg, indicating the need for additional therapy 1
• Thiazide-like diuretics have demonstrated efficacy in combination with beta-blockers and have shown good outcomes in reducing cardiovascular events 2

Specific Medication Recommendations

• Chlorthalidone 12.5mg daily is preferred over hydrochlorothiazide due to:

  • Longer duration of action (24-hour coverage) 3
  • Superior 24-hour ambulatory blood pressure reduction compared to hydrochlorothiazide 4
  • Effective blood pressure reduction even at low doses (6.25-12.5mg) 3

• Alternative option: Indapamide 1.25-2.5mg daily, which also provides extended duration of action 2

Implementation Strategy

1. Start with low-dose chlorthalidone 12.5mg daily to minimize potential side effects 5
2. Schedule follow-up within 4-6 weeks to assess blood pressure response 2
3. Monitor electrolytes and renal function 1-2 weeks after initiating therapy 2
4. If blood pressure remains uncontrolled after 4-6 weeks, consider:
   • Increasing chlorthalidone to 25mg daily 1
   • Adding a calcium channel blocker as a third agent if needed 1

Monitoring for Adverse Effects

• Check electrolytes (particularly potassium) and renal function within 1-2 weeks of starting therapy 2
• Monitor for potential adverse effects including:
  • Electrolyte disturbances (hypokalemia, hyponatremia)
  • Hyperuricemia
  • Glucose intolerance 2

Target Blood Pressure Goals

• Aim for blood pressure <140/90 mmHg within 3 months of treatment adjustment 1
• For patients with diabetes or chronic kidney disease, target <130/80 mmHg 1

Important Considerations

• Low-dose thiazide diuretics are effective while minimizing metabolic side effects 5
• The combination of beta-blockers with thiazide diuretics has been well-studied and is effective for blood pressure control 6
• If blood pressure remains uncontrolled despite optimized dual therapy, consider referral to a hypertension specialist 1

Lifestyle Modifications

• Reinforce the importance of:
  • Sodium restriction (<2g/day)
  • Regular physical activity
  • Weight management
  • Limiting alcohol consumption 2