What adjustments should be made to the patient's antihypertensive therapy to achieve better blood pressure control given their current regimen and elevated blood pressure?

Blood Pressure Management Adjustment

This patient requires intensification of their antihypertensive regimen by adding a thiazide-like diuretic (chlorthalidone 25 mg is already prescribed but adherence should be verified) or optimizing current therapy, as they have uncontrolled stage 1 hypertension (148/76 mmHg) on a three-drug regimen. 1

Current Regimen Assessment

The patient is currently on:

• Amlodipine 10 mg daily (calcium channel blocker at maximum dose) 2
• Losartan 50 mg daily (ARB at submaximal dose) 3
• Chlorthalidone 25 mg daily (thiazide-like diuretic) 1

This represents appropriate triple therapy with complementary mechanisms, but the blood pressure of 148/76 mmHg indicates inadequate control (target <140/90 mmHg for most patients). 1

Recommended Adjustments

First Priority: Verify Medication Adherence

• Poor adherence is the most common cause of apparent treatment resistance and must be excluded before intensifying therapy 1
• Review the patient's complex 13-medication regimen for potential barriers to adherence 4
• Consider once-daily dosing optimization and single-pill combinations to improve compliance 1

Second Priority: Optimize Current Medications

Increase losartan to 100 mg daily as the patient is only on 50% of the maximum dose, which can provide additional blood pressure reduction of 5-6 mmHg. 3 The FDA label indicates losartan is effective up to 100 mg daily, and the patient is currently on a submaximal dose. 3

Third Priority: Add Fourth-Line Agent if Needed

If blood pressure remains uncontrolled after optimizing losartan:

Add low-dose spironolactone (25 mg daily) as the fourth-line agent, provided: 1

• Serum potassium <4.5 mmol/L
• eGFR >45 mL/min/1.73m²
• No contraindications exist

Alternative fourth-line agents if spironolactone is contraindicated: 1

• Amiloride
• Doxazosin
• Eplerenone
• Clonidine
• Beta-blocker (though the patient is already on alprazolam and buspirone, which may complicate this choice)

Exclude Pseudoresistance and Secondary Causes

Before labeling this as resistant hypertension, confirm: 1

Proper blood pressure measurement technique:

• Use validated automated device with appropriate cuff size 1
• Obtain average of 2-3 readings at each visit 1
• Consider home blood pressure monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg) to exclude white coat effect 1

Screen for interfering substances: 1

• NSAIDs (patient is on diclofenac 75 mg twice daily) - this is a critical issue as NSAIDs significantly impair blood pressure control 1
• Consider switching to acetaminophen for pain management, as it has less impact on blood pressure than NSAIDs 1
• Review other medications: cyclosporine (known to cause hypertension), duloxetine, and gabapentin for potential blood pressure effects

Consider secondary hypertension screening if: 1

• Blood pressure remains uncontrolled despite optimal four-drug therapy
• Patient has sudden deterioration in control
• Early onset hypertension or strong clinical clues suggest secondary causes

Monitoring Plan

Follow-up within 2-4 weeks after any medication adjustment to assess response 5, 6

Target blood pressure: <140/90 mmHg (or <130/80 mmHg if home monitoring) 1

Monitor for adverse effects: 6

• Hyperkalemia (especially if adding spironolactone with existing ARB)
• Renal function (serum creatinine and potassium at least 1-2 times yearly) 1
• Orthostatic hypotension (particularly given patient's age and multiple medications)

Critical Pitfalls to Avoid

Do not use PRN antihypertensives for chronic blood pressure management - the patient's BP of 148/76 mmHg does not warrant episodic IV or PRN therapy, which is associated with adverse outcomes and should only be used for SBP >180-200 mmHg with symptoms 7

Address the NSAID issue immediately - diclofenac is likely contributing significantly to treatment resistance and should be discontinued or minimized 1

Avoid combining ACE inhibitors with ARBs - the patient is appropriately on losartan alone, not in combination with an ACE inhibitor 6

Do not lower diastolic pressure excessively - while the systolic BP needs reduction, avoid dropping diastolic BP below 60 mmHg, which may increase coronary risk in patients with potential coronary disease 1