Discontinuing Hydralazine in This Patient
You can safely discontinue hydralazine in this patient, but you must maintain the metoprolol and ensure adequate diuretic therapy throughout the discontinuation process to prevent rebound hypertension. 1
Key Considerations Before Discontinuation
This patient is already on metoprolol succinate 100mg ER daily and dapagliflozin (Farxiga), which provides the necessary beta-blockade and diuretic coverage required when stopping hydralazine. 1
Why Hydralazine Requires Special Discontinuation Protocol
- Hydralazine causes increased sympathetic tone and sodium retention, which is why guidelines mandate it should always be used with both a beta-blocker and diuretic. 2, 1
- The sympathetic activation and sodium retention persist during withdrawal, creating risk for rebound hypertension if protective medications are removed. 1
- Abrupt discontinuation significantly increases rebound hypertension risk, particularly if beta-blockers are stopped simultaneously. 1
Recommended Discontinuation Protocol
Step 1: Verify Protective Medications Are in Place
- Confirm the patient continues metoprolol succinate 100mg ER daily - this counteracts the increased sympathetic tone from hydralazine withdrawal. 2, 1
- Ensure adequate diuretic therapy - the patient is on dapagliflozin 10mg daily, which addresses sodium retention. 1
Step 2: Taper Hydralazine Gradually
- Do NOT stop hydralazine abruptly - taper the dose over 1-2 weeks. 1
- Current dose is 25mg three times daily (75mg total daily)
- Suggested taper: Reduce to 25mg twice daily for 3-5 days, then 25mg once daily for 3-5 days, then discontinue
Step 3: Monitor Blood Pressure Closely
- Check blood pressure every 2-3 days during the taper and for one week after complete discontinuation. 1
- The patient has a Dexcom G7 sensor, suggesting good self-monitoring capability - leverage this for home BP monitoring
Critical Pitfalls to Avoid
Never discontinue the metoprolol at the same time as hydralazine - abrupt beta-blocker cessation itself causes rebound hypertension, and the combination dramatically increases risk. 1
Do not reduce diuretic therapy during this process - the sodium retention from hydralazine persists during withdrawal. 1
Why This Patient Is a Good Candidate for Discontinuation
This patient has excellent blood pressure coverage without hydralazine:
- Lisinopril 20mg (ACE inhibitor) 2
- Metoprolol succinate 100mg ER (beta-blocker) 2
- Dapagliflozin 10mg (SGLT2 inhibitor with diuretic effect) 2
- Lovastatin and fenofibrate (lipid management supporting cardiovascular health)
Hydralazine is typically reserved as a 5th or 6th-line agent in resistant hypertension, added only after optimizing ACE inhibitors/ARBs, calcium channel blockers, diuretics, mineralocorticoid receptor antagonists, and beta-blockers. 2 This patient's regimen suggests hydralazine may have been added during a period of poor control that has since improved.
Additional Context on Hydralazine Use
Total daily hydralazine doses should remain below 150mg to avoid drug-induced lupus-like syndrome. 2, 1 This patient's current dose of 75mg daily is below this threshold, but discontinuation eliminates this long-term risk entirely.
Hydralazine requires background beta-blocker and diuretic therapy because it causes reflex tachycardia and profound sodium avidity. 2 The American Heart Association guidelines for resistant hypertension position hydralazine as Step 5 therapy, only after maximizing other agents. 2