How to manage hypertension in an elderly patient with a history of dizziness on hydrochlorothiazide (HCTZ), impaired renal function, and multiple comorbidities?

Management of Hypertension in an Elderly Patient with Dizziness and Impaired Renal Function

For this 80-year-old male with elevated blood pressure (160/106 mmHg) and history of dizziness on hydrochlorothiazide (HCTZ), a calcium channel blocker (CCB) should be initiated as first-line therapy rather than resuming HCTZ.

Patient Assessment

• Patient presents with elevated blood pressure (160/106 mmHg) after discontinuation of HCTZ due to dizziness episodes 1
• Relevant comorbidities include:
  • Impaired renal function (eGFR 55 mL/min/1.73m², creatinine 1.32 mg/dL) 1
  • Peripheral neuropathy 1
  • Benign prostatic hyperplasia (BPH) without obstruction 1
  • Age 80 years (requiring careful medication selection) 1
• Laboratory findings show metabolic acidosis (CO2 19 mmol/L, Chloride 109 mmol/L) 2

Treatment Recommendations

First-Line Therapy

• Initiate a long-acting dihydropyridine calcium channel blocker (DHP-CCB) such as amlodipine as first-line therapy 1
  • CCBs are preferred in elderly patients with impaired renal function and history of dizziness on diuretics 1
  • They have minimal adverse metabolic effects and are less likely to cause orthostatic hypotension than diuretics 1

Alternative Options (if CCB not tolerated)

• Consider a low-dose angiotensin receptor blocker (ARB) as an alternative 1
  • ARBs are preferred over ACE inhibitors in elderly patients due to lower risk of cough 1
  • Start at the lowest dose and titrate slowly to minimize risk of orthostatic hypotension 1

Medications to Avoid

• Do not restart hydrochlorothiazide given the patient's history of dizziness and impaired renal function 3, 4
  • Thiazide diuretics can worsen orthostatic hypotension in elderly patients 4
  • Although some evidence suggests thiazides may still be effective in CKD, the risk of electrolyte abnormalities is high 2, 5
• Avoid beta-blockers unless compelling indications exist (not present in this case) 1
• Avoid alpha-blockers due to increased risk of orthostatic hypotension, especially with concurrent BPH medication 1

Blood Pressure Goals

• Target blood pressure should be 130-139/80-89 mmHg 1
  • Less aggressive target is appropriate given patient's age and history of dizziness 1
  • Follow the "as low as reasonably achievable" (ALARA) principle without causing adverse effects 1
• Avoid excessive BP lowering (>20-25% reduction in first 24 hours) to prevent orthostatic symptoms 6

Monitoring Plan

• Check orthostatic blood pressure before initiating new medication 1
  • Measure BP after 5 minutes of sitting/lying and then 1 and 3 minutes after standing 1
• Schedule follow-up within 2-4 weeks to assess medication efficacy and tolerability 1
• Monitor electrolytes and renal function within 2-4 weeks of starting new medication 1
• Recommend home blood pressure monitoring to detect orthostatic changes 1

Special Considerations

• Screen for orthostatic hypotension before and after initiating therapy 1
• Consider frailty assessment to guide treatment intensity 1
• If dizziness persists with CCB, consider further dose reduction or switching to ARB 1
• If BP remains uncontrolled on monotherapy after 4-6 weeks, consider adding a second agent at low dose rather than maximizing the first agent 1

Patient Education

• Explain importance of gradual position changes (sitting before standing) to minimize orthostatic symptoms 1
• Emphasize importance of consistent medication timing and adherence 1
• Advise on salt moderation rather than strict restriction to avoid electrolyte imbalances 4
• Instruct patient to record home BP readings and any symptoms of dizziness 1