What is the best management plan for a patient with cervical radiculopathy presenting with left shoulder and arm tingling, numbness, and pain, and suboptimal hypertension control on Losartan?

Management of Cervical Radiculopathy with Concurrent Hypertension

For this 51-year-old patient with likely C5/C6 cervical radiculopathy and suboptimal blood pressure control (152/83 mmHg on losartan 50mg), the losartan dose should be increased to 100mg daily, and the cervical radiculopathy management plan with celecoxib, amitriptyline, and cervical spine imaging is appropriate, though NSAIDs may attenuate losartan's antihypertensive effect.

Hypertension Management Priority

Current Blood Pressure Status

• BP of 152/83 mmHg represents suboptimal control requiring intensification of therapy. The International Society of Hypertension establishes that blood pressure control must be a priority, as differences of 20/10 mmHg are associated with 50% differences in cardiovascular risk 1
• The patient is on losartan 50mg daily, which represents a subtherapeutic dose for many patients 2

Losartan Dose Optimization

• The European Journal of Heart Failure indicates that 50mg daily losartan appears inferior to ACE inhibitors for cardiovascular outcomes, with an optimal dose of 150mg daily for heart failure (though the US-approved maximum for hypertension is 100mg daily). 2
• Increase losartan to 100mg daily as the next step, as this represents the standard maximum approved dose for hypertension and provides superior blood pressure control compared to 50mg 2
• The patient's reluctance to increase medication should be addressed by explaining that current BP (152/83) significantly increases stroke and cardiovascular risk 1

Alternative Antihypertensive Strategies if Needed

• If BP remains ≥160/100 mmHg after losartan uptitration, add a calcium channel blocker (amlodipine 5mg daily) or thiazide diuretic (indapamide 2.5mg daily) per standard treatment algorithms 1
• The 2020 ISH guidelines support adding these agents as second-line therapy when monotherapy is insufficient 1

Cervical Radiculopathy Management

Diagnostic Approach

• The clinical presentation strongly suggests C5/C6 nerve root compression: constant tingling/numbness radiating from left shoulder to all fingers, worse when lying down, with reproducible symptoms on examination 3, 4
• Cervical spine X-ray is appropriate as initial imaging, though MRI would provide superior visualization of disc herniation and nerve root compression if symptoms persist 4, 5
• Normal neurological examination (power, reflexes, sensation) does not exclude radiculopathy, as early compression may present with pain and paresthesias before motor deficits develop 3

Pharmacological Management of Radiculopathy

Critical Drug Interaction Alert:

• Celecoxib (NSAID) will significantly attenuate losartan's antihypertensive effect. A multicenter study demonstrated that indomethacin attenuated losartan's 24-hour ambulatory diastolic BP reduction by 2.2 mmHg 6
• This interaction necessitates more aggressive BP monitoring during celecoxib therapy, with home BP measurements at least twice daily 6
• Consider limiting celecoxib duration to 2-4 weeks for acute inflammation management, then reassess need for continuation 5

Neuropathic Pain Management:

• Amitriptyline 10mg at night, titrating by 10mg every 3-7 days to maximum 75mg is evidence-based for neuropathic pain 5
• The counseling provided regarding drowsiness and appetite changes is appropriate 5
• Alternative agents if amitriptyline is not tolerated include gabapentin or pregabalin, though these were not prescribed 5

Non-Pharmacological Interventions

• Physical therapy and cervical traction may provide temporary decompression and symptom relief 5
• Short-term cervical collar use (not exceeding 1-2 weeks) may help during acute exacerbations, but prolonged use should be avoided to prevent muscle deconditioning 5
• The previous provider's recommendation of "exercise only" was inadequate given the severity (8/10 pain) and constant nature of symptoms 5

Integrated Management Strategy

Immediate Actions (Week 1-2)

• Increase losartan to 100mg daily immediately 2
• Start celecoxib 100mg twice daily with food, but counsel patient about BP monitoring requirements 6
• Begin amitriptyline 10mg at bedtime 5
• Obtain cervical spine X-rays 4
• Implement home BP monitoring twice daily (morning and evening) 1

Short-Term Follow-up (Week 3-4)

• Review cervical spine X-ray results; if negative but symptoms persist, obtain MRI 4
• Assess BP response: if still ≥140/90 mmHg despite losartan 100mg, add amlodipine 5mg daily or indapamide 2.5mg daily 1
• Titrate amitriptyline to 20-30mg if symptoms persist and initial dose tolerated 5
• Consider discontinuing celecoxib if inflammation controlled, to eliminate NSAID-losartan interaction 6
• Review blood work results (FBC, U&Es, LFTs, lipids) 1

Medium-Term Management (6-12 weeks)

• Most cervical radiculopathy improves with conservative management within 6-12 weeks 5
• If symptoms persist despite 6-8 weeks of optimal medical management, refer to spine specialist for consideration of epidural steroid injection or surgical evaluation 4, 5
• Target BP <140/90 mmHg; if not achieved on losartan 100mg plus one additional agent, consider referral to hypertension specialist 1

Critical Monitoring Parameters

Blood Pressure Monitoring

• Home BP measurements twice daily during celecoxib therapy 6
• Target <140/90 mmHg per standard guidelines 1
• If BP remains ≥160/100 mmHg on multiple readings, urgent intensification required 1

Radiculopathy Red Flags Requiring Urgent Referral

• Progressive motor weakness (currently absent but must monitor) 3, 4
• Bowel or bladder dysfunction suggesting myelopathy 4
• Bilateral symptoms with gait disturbance 4
• Severe, unremitting pain despite maximal medical therapy 5

Laboratory Monitoring

• Renal function (U&Es) at 2-4 weeks after losartan dose increase, as ARBs can cause acute kidney injury in susceptible patients 1
• Potassium levels, particularly if adding aldosterone antagonist later 1
• Liver function if amitriptyline dose escalated significantly 5

Addressing Patient Reluctance

The patient's reluctance to increase losartan requires direct counseling:

• Current BP of 152/83 mmHg increases stroke risk substantially compared to controlled BP 1
• Asian populations (given New Zealand context with Privacy Act 2020 reference) have particularly high stroke risk from uncontrolled hypertension 1
• Losartan 50mg is a subtherapeutic dose for most patients, and 100mg is still within standard dosing 2
• The addition of celecoxib will further impair BP control, making losartan dose increase even more critical 6