What is the next step in therapy for a patient with uncontrolled hypertension (High Blood Pressure) despite 2 weeks of lisinopril (Zestril) 5 mg therapy?

From the Guidelines

The next step in therapy for a patient with uncontrolled hypertension despite 2 weeks of lisinopril 5 mg therapy would be to increase the dose to 10 mg daily or add a second antihypertensive medication from a different class, such as a thiazide diuretic or a calcium channel blocker, as recommended by the most recent guidelines 1. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension, the recommended treatment for resistant hypertension includes reinforcement of lifestyle measures, addition of low-dose spironolactone to existing treatment, or addition of further diuretic therapy if intolerant to spironolactone 1. However, since the patient has only been on lisinopril 5 mg for 2 weeks, it is not considered resistant hypertension yet. The guidelines also suggest that in patients with uncontrolled BP despite use of first-line BP-lowering therapies, the addition of spironolactone to existing treatment should be considered 1. However, the first step would be to optimize the current treatment regimen, which includes increasing the dose of lisinopril or adding a second antihypertensive medication from a different class. Some key points to consider when managing uncontrolled hypertension include:

• Increasing the dose of lisinopril to 10 mg daily, as it is a common practice to titrate upward when the initial dose doesn't achieve target blood pressure 1
• Adding a second antihypertensive medication from a different class, such as a thiazide diuretic or a calcium channel blocker, to provide complementary mechanisms of action 1
• Monitoring blood pressure regularly during dose adjustments and assessing for potential side effects such as cough, dizziness, or electrolyte disturbances 1
• Continuing lifestyle modifications, including sodium restriction, weight loss if applicable, regular exercise, and limiting alcohol consumption, alongside medication therapy 1

From the FDA Drug Label

DOSAGE & ADMINISTRATION 2. 1 Hypertension Initial Therapy in adults: The recommended initial dose is 10 mg once a day. Dosage should be adjusted according to blood pressure response. The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose. If blood pressure is not controlled with lisinopril tablets alone, a low dose of a diuretic may be added (e.g., hydrochlorothiazide, 12. 5 mg).

The next step in therapy for a patient with uncontrolled hypertension despite 2 weeks of lisinopril (Zestril) 5 mg therapy is to:

• Increase the dose of lisinopril to achieve a dose within the usual dosage range of 20 mg to 40 mg per day, as the patient is currently below this range.
• Alternatively, add a low dose of a diuretic, such as hydrochlorothiazide 12.5 mg, to the current lisinopril regimen. 2

From the Research

Next Steps in Therapy for Uncontrolled Hypertension

• If a patient's hypertension remains uncontrolled after 2 weeks of lisinopril (Zestril) 5 mg therapy, the next step could involve increasing the dose of lisinopril or adding another antihypertensive medication, as seen in studies 3, 4.
• According to the study 4, if after 2 weeks the mean level of systolic blood pressure (SBP) and diastolic blood pressure (DBP) does not reduce by 10% or more from baseline, the dose of lisinopril can be doubled without changing the dose of amlodipine, if amlodipine is being used in combination.
• Another approach could be to combine lisinopril with a calcium channel blocker like amlodipine, as this combination has been shown to be effective in treating hypertension, especially in patients with comorbidities like arteriosclerosis obliterans 4.
• The combination of lisinopril with hydrochlorothiazide (HCTZ) has also been found to be effective in controlling blood pressure in patients with hypertension, as demonstrated in the study 5.
• It's important to monitor patients for potential side effects of lisinopril and other antihypertensive medications, including severe pancytopenia, although this is rare 6.
• The choice of the next step in therapy should be based on the individual patient's response to treatment, their medical history, and the presence of any comorbid conditions, considering the findings from studies 3, 7, 5.