From the Guidelines
For this 70-year-old male with uncontrolled hypertension despite being on lisinopril/HCTZ 20/25mg and metoprolol ER 50mg, I recommend adding a calcium channel blocker, such as amlodipine 5mg daily, as a third agent, as suggested by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This approach is supported by the guidelines, which recommend combining drugs from different classes to achieve greater blood pressure reduction and suggest that single-pill combinations are preferred for simplicity and adherence. Before adding medication, it is crucial to ensure proper adherence to the current regimen and confirm blood pressure readings with multiple measurements. Consider increasing the metoprolol ER to 100mg daily if heart rate control allows, as the current dose may be suboptimal. Lifestyle modifications remain essential, including sodium restriction to less than 2g daily, regular physical activity, weight management, and limiting alcohol consumption. Home blood pressure monitoring is valuable to track response to therapy changes. If adding amlodipine doesn't achieve target blood pressure (typically <130/80 mmHg), consider referral to a hypertension specialist, as resistant hypertension at this age may warrant evaluation for secondary causes such as renal artery stenosis, primary aldosteronism, or obstructive sleep apnea. The choice of amlodipine is based on its efficacy and safety profile, as well as its complementary mechanism of action to the patient's current medications, as noted in the guidelines 1. It's also important to note that the 2015 American Heart Association statement on the treatment of hypertension in patients with coronary artery disease supports the use of a calcium channel blocker in certain cases 1, but the most recent and highest quality evidence from the 2024 ESC guidelines 1 prioritizes the use of combination therapy with a focus on single-pill combinations for improved adherence and outcomes.
From the FDA Drug Label
DRUG INTERACTIONS 7. 1 Diuretics Initiation of lisinopril in patients on diuretics may result in excessive reduction of blood pressure. The possibility of hypotensive effects with lisinopril can be minimized by either decreasing or discontinuing the diuretic or increasing the salt intake prior to initiation of treatment with lisinopril. The patient is already on lisinopril 20/hctx 25 combo and metrolrolol 50 ER for hypertension (HTN), and the blood pressure is still not controlled. The current regimen includes a diuretic (HCTZ 25), and the patient is also on an ACE inhibitor (lisinopril). To minimize the risk of hypotension, the dose of lisinopril or diuretic could be adjusted, or salt intake could be increased. However, the optimal approach to manage uncontrolled hypertension in this patient would require careful consideration of the individual's overall clinical profile, including renal function, electrolyte levels, and other comorbidities. Given the complexity of this case and the potential risks associated with combined therapy, close monitoring of the patient's blood pressure, renal function, and electrolytes is essential 2.
From the Research
Uncontrolled Hypertension in a 70-year-old Male
- The patient is currently on lisinopril 20/hctx 25 combo and metrolrolol 50 ER for hypertension, but blood pressure remains uncontrolled 3, 4, 5.
- According to the study by 3, combination antihypertensive therapy is an important option that combines efficacy of blood pressure reduction and a low side effect profile with convenient once-daily dosing to enhance compliance.
- The patient's current medication includes an ACE inhibitor (lisinopril) and a beta blocker (metrolrolol), which are commonly used in combination therapy for hypertension 6, 7.
- The study by 6 found that different combinations of antihypertensive therapy, including lisinopril and hydrochlorothiazide, were equally effective in reducing blood pressure and improving arterial stiffness in patients with essential hypertension.
- The American Family Physician recommends that more than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents, either initially as combination therapy or as add-on therapy if monotherapy and lifestyle modifications do not achieve adequate blood pressure control 7.
Potential Next Steps
- Consider adding a calcium channel blocker or a thiazide diuretic to the patient's current medication regimen to enhance blood pressure control 3, 7.
- Monitor the patient's blood pressure and adjust the medication regimen as needed to achieve adequate blood pressure control 6.
- Lifestyle modifications, such as diet and exercise, should also be encouraged to help manage hypertension 3, 7.