From the Guidelines
For a patient whose blood pressure is not adequately controlled on amlodipine/olmesartan 10/40 mg, the next step would be to add a thiazide diuretic, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This approach is based on the principle that combining drugs from different classes can have additive or synergistic effects, leading to greater blood pressure reduction than increasing the dose of one drug. The major four drug classes, including dihydropyridine CCBs (such as amlodipine), ARBs (such as olmesartan), and thiazide or thiazide-like diuretics, are recommended as first-line BP-lowering medications, either alone or in combination 1. Some key points to consider when adding a thiazide diuretic include:
- Starting with a low dose, such as hydrochlorothiazide (HCTZ) 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily
- Monitoring electrolytes, particularly potassium and sodium, within 1-2 weeks of adding the diuretic
- Considering a loop diuretic like furosemide 20-40 mg once or twice daily instead of a thiazide if the patient has reduced kidney function (eGFR <30 ml/min) If blood pressure remains uncontrolled after adding a diuretic, consider adding a fourth agent such as spironolactone 25 mg daily (especially effective in resistant hypertension) or a beta-blocker like metoprolol 25-100 mg twice daily, as suggested by the 2024 ESC guidelines 1.
From the Research
Treatment Options for Uncontrolled Blood Pressure
If a patient's blood pressure is not controlled with amlodipine olmesartan 10/40, several options can be considered to add to the treatment regimen.
- Adding Hydrochlorothiazide: Studies have shown that adding hydrochlorothiazide (HCTZ) to olmesartan/amlodipine can increase efficacy in patients with inadequate blood pressure control on dual-combination therapy 2.
- Uptitration of Therapy: A treatment algorithm based on olmesartan/amlodipine (+/- HCTZ) provides a high degree of blood pressure control in patients with moderate-to-severe hypertension 3.
- Fixed-Dose Combination: Fixed-dose combination formulations of olmesartan medoxomil, an angiotensin receptor blocker (ARB), and the calcium channel blocker (CCB) amlodipine, with or without hydrochlorothiazide, have demonstrated greater efficacy than their component monotherapies in reducing blood pressure in patients with mild-to-severe hypertension 4, 5, 6.
Efficacy and Safety of Triple-Combination Therapy
Triple-combination therapy with olmesartan medoxomil, amlodipine besylate, and hydrochlorothiazide has been shown to be effective and safe for the treatment of hypertension 6.
- Long-Term Efficacy: Long-term treatment with this triple-combination therapy was well tolerated and effective, with no new safety concerns 6.
- Blood Pressure Reduction: The mean blood pressure decreased significantly from baseline to the end of the study, with 44.5% to 79.8% of participants reaching blood pressure goal 6.