How to manage a patient with uncontrolled hypertension and fatigue, who has not been taking their prescribed antihypertensive medications?

Management of Uncontrolled Hypertension After Medication Non-Adherence

Immediate Action: Restart Previous Medications and Add Third Agent

This patient requires immediate reinitiation of both losartan 50mg and felodipine 5mg daily, with prompt addition of a third antihypertensive agent given the BP of 158/66 mmHg after one week without medications. 1

• The patient's previous regimen of losartan (ARB) plus felodipine (dihydropyridine calcium channel blocker) should be restarted immediately, as these are appropriate first-line agents that were previously controlling BP 1, 2, 3
• With current BP 158/66 mmHg (Stage 2 hypertension), the 2020 ISH guidelines recommend initiating two-drug therapy for BP ≥140/90 mmHg, but since this patient was previously controlled on two drugs, adding a third agent is appropriate 1
• Add a thiazide-like diuretic (chlorthalidone 12.5-25mg daily or indapamide 2.5mg daily) as the third agent, as multiple-drug therapy is required to achieve BP targets and thiazide-like diuretics provide superior cardiovascular outcomes compared to thiazides 1, 4

Blood Pressure Target

• Target BP should be <130/80 mmHg for this elderly patient, with individualization based on frailty status 1
• The 2020 ISH guidelines recommend achieving target BP within 3 months of treatment initiation 1

Addressing the Fatigue

The fatigue with minimal exertion requires urgent investigation before attributing it to hypertension alone. 4

• The ordered investigations (FBC, ferritin, TFTs, glucose) are appropriate to exclude anemia, thyroid dysfunction, and diabetes as causes of fatigue 4
• Fatigue could represent end-organ damage from uncontrolled hypertension (cardiac dysfunction, renal impairment), which the U&Es and clinical assessment will help identify 1
• Do not attribute fatigue solely to medication cessation—this symptom warrants complete workup before assuming it will resolve with BP control alone 1

Monitoring Requirements

Serum creatinine, eGFR, and potassium must be checked within 2-4 weeks after restarting the ARB and adding the diuretic. 1, 4

• BP should be rechecked within 2-4 weeks to assess response to the three-drug regimen 1, 4
• Home BP monitoring should be arranged to confirm office readings and exclude white coat hypertension 1
• Once stable, monitor potassium and creatinine at least annually 4

Addressing Medication Adherence

Before diagnosing resistant hypertension, medication non-adherence must be addressed as the primary issue in this case. 1, 5

• The patient's recent immigration and medication supply running out suggests logistical barriers rather than intentional non-adherence 1
• Ensure adequate medication supply is arranged, with consideration of single-pill combination therapy to improve adherence 1
• Provide clear written instructions in the patient's preferred language and arrange follow-up within 2 weeks to reinforce adherence 1
• Address cost barriers and simplify the regimen where possible—once-daily dosing of all three agents improves adherence 1

If Blood Pressure Remains Uncontrolled

If BP remains ≥140/90 mmHg on three medications (ARB + CCB + thiazide-like diuretic) at optimal doses after 3 months, add spironolactone 12.5-25mg daily as fourth-line therapy. 1, 5

• Before adding a fourth agent, confirm true resistant hypertension by excluding pseudoresistance (poor BP measurement, white coat effect, non-adherence) 1, 5
• Spironolactone is the preferred fourth-line agent for resistant hypertension, with potassium monitored closely (contraindicated if K+ >4.5 mmol/L or eGFR <45 mL/min/1.73m²) 1, 5
• Alternative fourth-line agents include amiloride, doxazosin, eplerenone, clonidine, or beta-blockers 1, 5
• Refer to a specialist with hypertension expertise if BP remains uncontrolled on four agents or if secondary hypertension is suspected 1

Common Pitfalls to Avoid

• Never combine an ACE inhibitor with an ARB—this increases risk of hyperkalemia and AKI without cardiovascular benefit 1, 4
• Do not use loop diuretics as first-line therapy—thiazide-like diuretics are superior for cardiovascular outcomes 4, 6
• Avoid bedtime dosing of antihypertensives—recent trials show no benefit over morning dosing 1
• Do not stop the ARB if creatinine increases by <30%—modest increases are expected and acceptable 4
• Do not diagnose resistant hypertension without confirming adherence and excluding white coat effect 1, 5

Lifestyle Modifications

Reinforce lifestyle interventions alongside medication restart, as these provide additive BP-lowering effects. 1, 6

• Dietary sodium restriction (<2g/day), increased potassium intake, and DASH or Mediterranean dietary pattern 1, 6
• Weight loss if indicated (not specified in this case) 1, 6
• Regular physical activity (150 minutes/week moderate intensity) 1, 6
• Limited alcohol consumption 6, 5