Can I start diuretics (thiazide diuretics) or Angiotensin Receptor Blockers (ARBs) in older patients (age > 65)?

Can You Start Diuretics/ARBs in Older Patients (Age >65)?

Yes, both thiazide diuretics and ARBs can and should be started in patients over age 65 for hypertension management, as randomized trials have demonstrated significant reductions in cardiovascular morbidity and mortality in this age group. 1

Evidence Supporting Use in Elderly Patients

Thiazide Diuretics

• Randomized controlled trials specifically in elderly patients with systolic-diastolic or isolated systolic hypertension (age ≥60 years) have shown marked reductions in cardiovascular morbidity and mortality with thiazide diuretics. 1
• Thiazides are the only antihypertensive class proven to reduce cardiovascular events specifically in patients with isolated systolic hypertension, which is the predominant form of hypertension in the elderly. 2
• Low-dose thiazide regimens are efficacious in preventing cardiovascular events in adults aged 65 and older. 3

ARBs (Angiotensin Receptor Blockers)

• In the LIFE trial, the ARB losartan was more effective than beta-blockers in reducing cardiovascular events, particularly stroke, in hypertensive patients aged 55-80 years with left ventricular hypertrophy. 1
• Clinical trials in elderly patients (including 391 patients ≥65 years and 37 patients ≥75 years) showed no overall differences in effectiveness or safety compared to younger patients. 4
• ARBs are recommended as first-line agents for patients under 55-60 years, and can be used in combination therapy for older patients. 1

Critical Dosing and Initiation Considerations

For Thiazide Diuretics

• Start with the lowest available dose (hydrochlorothiazide 12.5 mg daily) in elderly patients, as greater blood pressure reduction and increased side effects may occur. 5
• If further titration is required, use 12.5 mg increments. 5
• Initial doses and subsequent dose titration should be more gradual in elderly patients, especially in very old and frail subjects, due to greater chance of adverse effects. 1

For ARBs

• No dose adjustment is necessary based on age alone. 4
• However, consider starting at 25 mg for losartan if the patient has hepatic impairment. 4

Important Monitoring Requirements

For Thiazide Diuretics

• Monitor renal function and electrolytes (particularly potassium and sodium) regularly, as elderly patients are at increased risk for hypovolemia, postural hypotension, falls, dehydration, and electrolyte disturbances. 1
• Always measure blood pressure in both sitting and standing positions due to increased risk of postural hypotension. 1
• Reassess blood pressure within 2-4 weeks after initiation. 6

For ARBs

• Monitor renal function and serum potassium, especially when combined with diuretics. 6
• No special monitoring beyond standard practice is required based on age alone. 4

Specific Contraindications and Cautions in Elderly

Thiazide Diuretics - Potentially Inappropriate in:

• Elderly patients with history of gout (increased risk of adverse events). 1, 3
• Patients with diabetes or hyperlipidemia (relative contraindication). 1
• CrCl <30 mL/min (ineffective at this level of renal function). 1
• Patients ≥75 years for ankle edema without signs of heart failure or as first-line monotherapy for hypertension. 1
• Patients with poor mobility or urinary incontinence (due to increased urination). 1

ARBs - Use with Caution in:

• Volume-depleted patients (increased risk of hypotension). 4
• Renal impairment (though no dose adjustment needed unless volume depleted). 4

Recommended Treatment Algorithm for Elderly Patients

First-Line Therapy Options

• For patients ≥55-60 years: Consider thiazide diuretics or calcium channel blockers as first-line agents. 1
• For patients <55-60 years: ARBs or ACE inhibitors are preferred first-line. 1

Combination Therapy Progression

• If blood pressure remains uncontrolled on monotherapy, the preferred two-drug combination is CCB + ARB. 6
• If blood pressure remains uncontrolled on dual therapy, add a thiazide diuretic as the third agent (CCB + ARB + thiazide). 6
• When combining ARB with thiazide, the ARB provides some protection against thiazide-induced hypokalemia. 6

Blood Pressure Goals in Elderly

• Target blood pressure is <140/90 mmHg for most elderly patients, if tolerated. 1
• For most patients aged ≥65 years, standard office systolic blood pressure should be cautiously reduced to between 130-140 mmHg. 7
• Many elderly patients need two or more drugs to achieve blood pressure control, and reductions to <140 mmHg systolic may be particularly difficult to obtain. 1

Common Pitfalls to Avoid

• Do not discontinue successful and well-tolerated therapy when a patient reaches 80 years of age. 1
• Avoid excessive diuresis in elderly patients with heart failure with preserved ejection fraction (HFpEF). 1
• Do not use loop diuretics as first-line therapy for hypertension in patients ≥75 years. 1
• Verify medication adherence before escalating therapy, as non-adherence is a common cause of apparent treatment resistance. 6