What is the best alternative antihypertensive agent for an 80-year-old male with hypertension, currently on irbesartan (Angiotensin II Receptor Blocker) 75 mg a day, who developed bradycardia and dizziness on metoprolol (Beta-Blocker) 25 mg twice daily?

Management of Hypertension in an 80-year-old Male After Discontinuing Metoprolol

For this 80-year-old male with hypertension who developed bradycardia and dizziness on metoprolol, adding a dihydropyridine calcium channel blocker (DHP-CCB) is the most appropriate next step to control blood pressure while avoiding the adverse effects experienced with beta-blockers. 1, 2

Patient Assessment and Considerations

• The patient is currently on irbesartan 75 mg daily (an ARB) with rising blood pressure after metoprolol discontinuation 3
• Metoprolol was discontinued due to bradycardia and dizziness, which are common adverse effects of beta-blockers, especially in elderly patients 1, 4
• Current heart rate of 80-90 bpm indicates resolution of bradycardia after metoprolol discontinuation 4
• Advanced age (80 years) requires careful consideration of medication selection and dosing 1

Recommended Treatment Approach

First-line Option:

• Add a dihydropyridine calcium channel blocker (DHP-CCB) such as amlodipine 2.5-5 mg daily 1
  • DHP-CCBs have shown excellent efficacy in elderly patients with systolic hypertension 5
  • They don't cause bradycardia and are well-tolerated in elderly patients 1, 6
  • Start with a low dose (2.5 mg) and titrate gradually to minimize vasodilatory side effects 1

Alternative Options (if DHP-CCB not tolerated):

• Add a thiazide-like diuretic such as chlorthalidone 12.5 mg or indapamide 1.25 mg daily 1, 7

  • Thiazide-like diuretics are particularly effective in elderly patients 5
  • They provide additive effects when combined with ARBs like irbesartan 3
  • Monitor for electrolyte disturbances, especially in the elderly 7

• Optimize irbesartan dosing by increasing to 150-300 mg daily if currently undertreated 3

  • Irbesartan at 150-300 mg provides significant BP reduction (8-12/5-8 mmHg) 3
  • Once-daily dosing provides 24-hour BP control 8

Monitoring Recommendations

• Recheck blood pressure within 4 weeks of medication adjustment 2, 7
• Target blood pressure control should be achieved within 3 months 1, 2
• For this 80-year-old patient, aim for a blood pressure goal of <140/90 mmHg if tolerated 1, 2
• Monitor for orthostatic hypotension by checking BP in both sitting and standing positions 1
• If adding a diuretic, check electrolytes and renal function 1-2 weeks after initiation 7

Important Considerations and Pitfalls

• Beta-blockers are often less effective for BP control in elderly patients compared to other antihypertensive classes 9, 5
• Avoid restarting metoprolol as the patient has already demonstrated intolerance with bradycardia and dizziness 9, 4
• Start with lower doses of any new medication and titrate more gradually in elderly patients 1
• Monitor for drug interactions between existing and new medications 8
• Assess orthostatic hypotension before and after medication changes, as this is common in elderly patients 1

Treatment Algorithm

1. Add amlodipine 2.5 mg daily and assess response in 2-4 weeks 1
2. If BP remains uncontrolled, increase amlodipine to 5 mg daily 1, 7
3. If BP still uncontrolled or amlodipine not tolerated, add or substitute a thiazide-like diuretic 1, 7
4. Consider increasing irbesartan to 150-300 mg daily if not at optimal dose 3
5. Target BP <140/90 mmHg, but individualize based on tolerability 1, 2