Which medication should be increased first in a patient with hypertension (HTN) on lisinopril (ACE inhibitor) 5mg once a day and metoprolol (beta blocker) 25mg with severely elevated blood pressure?

Management of Hypertension with Elevated Blood Pressure

In a patient with hypertension on lisinopril 5mg once daily and metoprolol 25mg with blood pressure over 180, the lisinopril should be increased first to 10-20mg daily before adjusting other medications.

Rationale for Increasing Lisinopril First

• The FDA-approved dosing for lisinopril indicates that the recommended initial dose for hypertension is 10mg once daily, with a usual dosage range of 20-40mg per day, suggesting the current 5mg dose is suboptimal 1
• The International Society of Hypertension (ISH) guidelines recommend a stepwise approach to blood pressure management, with increasing ACE inhibitors to full dose before adding additional agents 2
• Lisinopril at 5mg is considered a low starting dose, particularly used when initiating therapy in patients already on diuretics, and should be titrated upward for adequate blood pressure control 1
• Clinical studies have demonstrated that blood pressure reduction occurs sooner and is greater in patients treated with 10mg, 20mg, or 80mg of lisinopril compared to those treated with 5mg 1

Treatment Algorithm for Hypertension Management

• For non-black patients, the recommended approach is to start with low-dose ACE inhibitor/ARB (which has been done), then increase to full dose before adding or adjusting other medications 2, 3
• Severely elevated blood pressure (>180 systolic) requires prompt intervention to reduce cardiovascular risk, with immediate medication adjustment rather than waiting for lifestyle modifications 2
• The target should be to reduce blood pressure by at least 20/10 mmHg, ideally to <140/90 mmHg within 3 months 2
• Once lisinopril has been optimized to full dose (20-40mg), if blood pressure remains uncontrolled, the next step would be to add or increase the thiazide/thiazide-like diuretic 2, 3

Specific Dosing Considerations for Lisinopril

• Lisinopril dose should be increased to 10mg daily initially, with potential further titration to 20-40mg based on blood pressure response 1
• Dose adjustments should be made with monitoring after 2-4 weeks to assess efficacy and tolerability 3
• Lisinopril produces greater systolic and diastolic blood pressure reductions than hydrochlorothiazide and has been shown to be at least as effective as metoprolol in reducing diastolic blood pressure 1, 4
• Studies have shown that lisinopril doses of 10mg and 20mg daily produce similar peak antihypertensive effects, which are greater than that of 2.5mg daily but less than 80mg daily 5

Special Considerations and Monitoring

• Monitor for potential side effects of increased lisinopril dosing, including cough, hyperkalemia, and acute kidney injury 6
• If blood pressure remains uncontrolled after optimizing lisinopril dose, consider adding a thiazide diuretic before further increasing metoprolol 2, 3
• For black patients, a different approach may be considered as they may respond better to calcium channel blockers and diuretics than to ACE inhibitors, though the current regimen should still be optimized first 6, 3
• Avoid combining ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 6

Follow-up Recommendations

• Reassess blood pressure within 2-4 weeks after increasing lisinopril dose 3
• If blood pressure remains >140/90 mmHg after maximizing lisinopril dose, consider adding a thiazide/thiazide-like diuretic 2, 3
• Only consider increasing metoprolol if blood pressure remains uncontrolled after optimizing both lisinopril and adding a diuretic 2