Management of Persistent Hypertension in an 85-Year-Old Female on Lisinopril and Furosemide
Add a dihydropyridine calcium channel blocker (amlodipine 2.5-5 mg daily) as the next step to achieve blood pressure control in this elderly patient already on maximal ACE inhibitor therapy and a diuretic. 1
Rationale for Adding a Calcium Channel Blocker
The combination of an ACE inhibitor (lisinopril), diuretic (furosemide), and calcium channel blocker represents the cornerstone triple therapy for resistant hypertension. 2
- Amlodipine is particularly well-suited for elderly patients because it does not cause bradycardia and is generally well-tolerated in this age group 1
- Start with amlodipine 2.5 mg daily and titrate gradually to minimize vasodilatory side effects such as peripheral edema 1
- If blood pressure remains uncontrolled after 2-4 weeks, increase to amlodipine 5 mg daily 1
Target Blood Pressure Goals
- For this 85-year-old patient, aim for a blood pressure goal of <140/90 mmHg if tolerated 1
- While the general target for most adults is <130/80 mmHg, elderly patients require more cautious blood pressure reduction 3
- Monitor for orthostatic hypotension by checking blood pressure in both sitting and standing positions, as elderly patients are at higher risk for postural drops 1
Alternative Fourth-Line Agent
If amlodipine is not tolerated or contraindicated, consider adding spironolactone as the fourth-line agent:
- Spironolactone is the preferred fourth-line agent for resistant hypertension based on the PATHWAY-2 trial 2
- Start with low doses (12.5-25 mg daily) in elderly patients 2
- Monitor potassium levels closely, especially given concurrent ACE inhibitor use 4
- Alternative agents include amiloride, doxazosin, or eplerenone if spironolactone is contraindicated 2
Important Monitoring Considerations
- Recheck blood pressure within 4 weeks of adding amlodipine 1, 3
- Target blood pressure control should be achieved within 3 months 3
- Monitor serum electrolytes (particularly potassium), creatinine, and BUN frequently, especially in elderly patients on multiple antihypertensive agents 4
- Ensure medication adherence, as pseudo-resistance due to non-adherence is common 2
Critical Pitfalls to Avoid
- Do not discontinue the ACE inhibitor (lisinopril 40 mg) as it provides cardiovascular and renal protection beyond blood pressure control 5, 6
- Avoid excessive blood pressure reduction that could compromise organ perfusion in elderly patients 1
- Do not add a beta-blocker as the next agent in an elderly patient without specific cardiac indications, as they are less well-tolerated 1
- Verify that the patient is actually taking medications as prescribed before escalating therapy 2
- Confirm elevated blood pressure with home or ambulatory monitoring to exclude white coat hypertension 2
Dosing Considerations for Current Medications
- The current lisinopril dose of 40 mg daily is at the maximum recommended dose for hypertension 6
- Furosemide dosing appears appropriate, though the specific dose was not mentioned; typical dosing for hypertension is 40 mg twice daily 4
- In elderly patients, furosemide should be used cautiously with careful monitoring of electrolytes and renal function 4