What can be added to benazapril (angiotensin-converting enzyme inhibitor) 20mg and atenolol (beta blocker) to control hypertension in a 72-year-old female with tachycardia syndrome, given that amlodipine (calcium channel blocker) is not tolerated due to nightmares?

From the Guidelines

For a 72-year-old female with hypertension who is currently on benazepril 20mg and atenolol but still has high blood pressure readings, and who experiences nightmares with amlodipine, I would recommend adding a thiazide diuretic such as chlorthalidone 12.5mg daily or hydrochlorothiazide 12.5-25mg daily. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, thiazide diuretics are recommended as first-line treatments to lower blood pressure, particularly in combination with ACE inhibitors like benazepril. They reduce blood pressure by promoting sodium and water excretion, decreasing blood volume, and reducing peripheral vascular resistance.

The guidelines also suggest that combination BP-lowering treatment is recommended for most patients with confirmed hypertension as initial therapy, with preferred combinations including a RAS blocker with a dihydropyridine CCB or diuretic 1. In this case, adding a thiazide diuretic to the patient's current regimen of benazepril and atenolol would be a suitable option. It's essential to monitor electrolytes, particularly potassium, when adding a diuretic, and to check kidney function before and after starting any new antihypertensive medication.

Another option would be to consider a calcium channel blocker from a different class than amlodipine, such as diltiazem ER 120-180mg daily, which might not cause the same side effects. Alternatively, adding a low dose of spironolactone 12.5-25mg daily could be beneficial, especially if there's any suggestion of resistant hypertension 1. The patient should also be advised to continue lifestyle modifications including sodium restriction, regular exercise, and weight management as appropriate.

Key points to consider:

• Thiazide diuretics are effective in combination with ACE inhibitors like benazepril
• Monitor electrolytes, particularly potassium, when adding a diuretic
• Check kidney function before and after starting any new antihypertensive medication
• Consider alternative calcium channel blockers or spironolactone if necessary
• Continue lifestyle modifications to support blood pressure management 1.

From the FDA Drug Label

Benazepril hydrochloride has been used concomitantly with beta-adrenergic-blocking agents, calcium-channel-blocking agents, diuretics, digoxin, and hydralazine, without evidence of clinically important adverse interactions Benazepril, like other ACE inhibitors, has had less than additive effects with beta-adrenergic blockers, presumably because both drugs lower blood pressure by inhibiting parts of the renin-angiotensin system Atenolol has been studied in combination with thiazide type diuretics, and the blood pressure effects of the combination are approximately additive. Atenolol is also compatible with methyldopa, hydralazine, and prazosin, each combination resulting in a larger fall in blood pressure than with the single agents

The patient is already on benazapril and atenolol, and since amlodipine is not an option due to nightmares, other alternatives can be considered.

• Hydralazine or methyldopa could be added to the current regimen, as they have been shown to be compatible with atenolol and may provide additional blood pressure reduction.
• Diuretics, such as thiazide-type diuretics, could also be considered, as they have been used concomitantly with benazapril and atenolol without significant adverse interactions. It is essential to monitor the patient's blood pressure and adjust the treatment regimen accordingly, taking into account potential interactions and side effects 2 3.

From the Research

Alternative Treatment Options

To control the patient's high blood pressure, several alternative treatment options can be considered:

• Switching from amlodipine to a combination therapy with telmisartan and low-dose hydrochlorothiazide, as suggested by the study 4, which showed a significant reduction in blood pressure levels.
• Using a triple fixed-dose combination therapy with an angiotensin II receptor blocker, a calcium channel blocker, and a thiazide diuretic, as recommended by the European hypertension guidelines and supported by the study 5.
• Adding a thiazide diuretic to the patient's current treatment regimen, as suggested by the study 4, which showed that the combination of a RAS inhibitor and a low-dose thiazide diuretic is useful in controlling blood pressure.

Considerations for Treatment

When considering alternative treatment options, the following factors should be taken into account:

• The patient's current medication regimen, including benazapril and atenolol, and potential interactions with new medications.
• The patient's medical history, including the presence of any comorbidities, such as diabetes or chronic kidney disease.
• The patient's tolerance to different medications, including the occurrence of nightmares with amlodipine.

Potential Medications to Add

Based on the available evidence, the following medications could be considered to add to the patient's treatment regimen:

• Telmisartan, an angiotensin II receptor blocker, which has been shown to be effective in combination with low-dose hydrochlorothiazide 4.
• Hydrochlorothiazide, a thiazide diuretic, which has been shown to be effective in combination with telmisartan 4 and other medications.
• Olmesartan, an angiotensin II receptor blocker, which is available as a triple fixed-dose combination with amlodipine and hydrochlorothiazide, and has been shown to be effective in reducing blood pressure 5.