What medication to add to atenolol (beta-blocker) for a patient with uncontrolled hypertension?

Adding a Medication to Atenolol for Uncontrolled Hypertension

For a patient taking atenolol with uncontrolled hypertension, add a calcium channel blocker (preferably a dihydropyridine like amlodipine) as the next agent. 1

Why Atenolol May Not Be Optimal

• Atenolol is not recommended as a first-line agent for hypertension according to current guidelines 1
• The 2017 ACC/AHA guidelines specifically state that "the beta blocker atenolol should not be used because it is less effective than placebo in reducing cardiovascular events" 1
• For beta blockers, guidelines recommend carvedilol, metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, or timolol when beta blockade is needed 1

Best Option to Add to Atenolol

• A dihydropyridine calcium channel blocker (CCB) is the preferred add-on agent for patients with uncontrolled hypertension on beta blockers 1
• Amlodipine (2.5-10 mg daily) is a good choice as it can be administered once daily and has minimal drug interactions 1
• This combination provides complementary mechanisms of action: beta blockers reduce cardiac output while CCBs cause vasodilation 1

Alternative Options (If CCB Not Suitable)

1. Thiazide or thiazide-like diuretic:

   • Effective when combined with beta blockers 1, 2
   • Options include chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 12.5-25 mg daily 1

2. Mineralocorticoid receptor antagonist:

   • Spironolactone (25-100 mg daily) is particularly effective for resistant hypertension 1
   • Can provide significant additional BP reduction when added to existing multidrug regimens 1
   • Monitor for hyperkalemia, especially if combined with ACE inhibitors or ARBs 1

3. ACE inhibitor or ARB:

   • Can be added, but avoid combining ACE inhibitors with ARBs 1
   • Provides additional cardiovascular protection in specific populations 1

Special Considerations

• Consider replacing atenolol: If possible, consider switching from atenolol to a preferred beta blocker like metoprolol succinate or carvedilol 1
• Dosing optimization: Ensure atenolol is dosed appropriately (50-100 mg daily) before adding another agent 2
• Monitoring: After adding a new agent, reassess BP within 2-4 weeks to evaluate efficacy 1
• Target BP: Aim for BP <130/80 mmHg in most patients according to current guidelines 1

Algorithm for Add-on Therapy

1. First add-on: Dihydropyridine CCB (e.g., amlodipine 5-10 mg daily) 1
2. Second add-on: Thiazide-like diuretic if not already included 1
3. Third add-on: Mineralocorticoid receptor antagonist (spironolactone 25 mg daily) 1
4. Fourth add-on: Consider alpha-1 blocker (doxazosin) or other agents 1

Common Pitfalls to Avoid

• Don't combine non-dihydropyridine CCBs (diltiazem, verapamil) with beta blockers due to increased risk of bradycardia and heart block 1
• Avoid abrupt discontinuation of beta blockers, which can lead to rebound hypertension 1
• Don't use dual RAS blockade (combining ACE inhibitors with ARBs) due to increased risk of adverse events 1
• Monitor for peripheral edema when using dihydropyridine CCBs, especially in women 1