What is the next step in managing a patient with uncontrolled hypertension on Lisinopril (angiotensin-converting enzyme inhibitor) 10 mg once daily with blood pressure readings in the range of 140-160 mmHg?

Management of Uncontrolled Hypertension on Lisinopril 10 mg

Add a calcium channel blocker (CCB) to the current lisinopril regimen as the next step, as this patient has Grade 2 hypertension (≥160 mmHg systolic) requiring immediate intensification to dual therapy. 1

Immediate Action Required

• This patient has Grade 2 hypertension with systolic BP ≥160 mmHg, which requires immediate drug treatment intensification 1
• The current lisinopril 10 mg dose is suboptimal, as the FDA-approved usual dosage range is 20-40 mg daily for hypertension 2

Step-by-Step Management Algorithm

Option 1: Optimize Current Monotherapy First

• Increase lisinopril to 20 mg once daily, as this is within the standard dosage range and may provide adequate control 2
• The FDA label indicates doses up to 80 mg have been used, though 20-40 mg is the usual effective range 2
• However, given the severity of elevation (140s-160s), monotherapy optimization alone may be insufficient

Option 2: Add Combination Therapy (Preferred)

For non-Black patients:

• Add a CCB (such as amlodipine 5-10 mg daily) to the current lisinopril regimen 3, 1
• This ACE inhibitor + CCB combination is the recommended Step 2 treatment per guidelines 3

Alternative if CCB not suitable:

• Add a thiazide-like diuretic (chlorthalidone 12.5-25 mg once daily or indapamide 1.5 mg modified-release) if CCB causes edema, is not tolerated, or if heart failure risk exists 3
• The FDA label supports adding hydrochlorothiazide 12.5 mg if BP is not controlled with lisinopril alone 2

Blood Pressure Targets and Timeline

• Initial goal: Reduce BP by at least 20/10 mmHg 1
• Target BP: <130/80 mmHg for most adults 1
• Timeline: Aim to achieve target within 3 months 1

Follow-Up and Monitoring

• Schedule follow-up within 2-4 weeks to assess response to therapy 1
• Monitor medication adherence and side effects at each visit 1
• Implement home BP monitoring to track progress and improve adherence 1

Common Pitfalls to Avoid

• Don't delay intensification: With BP in the 160s range, this represents Grade 2 hypertension requiring prompt action rather than prolonged observation 1
• Don't use beta-blockers as second-line: If adding to an ACE inhibitor, use a CCB rather than a thiazide-like diuretic to reduce diabetes risk 3
• Assess for secondary causes: Particularly important with severe or resistant hypertension 1

When to Refer to Specialist

• If BP remains uncontrolled despite multiple medications, refer to a hypertension specialist 1
• Consider referral if resistant hypertension develops (uncontrolled on 3+ medications including a diuretic) 3