What management approach is recommended for a patient with uncontrolled hypertension, history of breast cancer, knee lump, and impaired renal function?

Management of Uncontrolled Hypertension with Multiple Comorbidities

For this 61-year-old patient with poorly controlled hypertension (BP 160/106 mmHg), impaired renal function (ACR abnormal, eGFR ~55 mL/min based on context), history of breast cancer, and dizziness on losartan, initiate amlodipine 5 mg daily as first-line therapy, with close monitoring for orthostatic hypotension and renal function. 1

Immediate Assessment Priorities

Check orthostatic blood pressure before any medication changes by measuring BP after 5 minutes of sitting/lying, then at 1 and 3 minutes after standing to quantify the dizziness symptoms. 2, 1

Key baseline evaluations needed:

• Confirm the abnormal ACR value and calculate precise eGFR using MDRD formula 3
• Assess for proteinuria quantification if not already done 2, 4
• Review medication adherence patterns—the patient reports taking losartan "PRN" which is inappropriate for hypertension management 5

Primary Hypertension Management Strategy

First-Line Medication Selection

Start amlodipine 5 mg once daily as the preferred agent for this patient. 1 This recommendation is based on:

• Renal protection: Long-acting dihydropyridine calcium channel blockers are appropriate for patients with CKD stage 3 2, 1
• Tolerability profile: Lower risk of orthostatic hypotension compared to diuretics or high-dose ARBs in elderly patients with dizziness history 1
• Cancer history compatibility: No contraindications in breast cancer survivors 2

The patient's previous dizziness on losartan likely represents either orthostatic hypotension or inadequate dosing/adherence rather than true drug intolerance. 5

Blood Pressure Target

Target BP of 130-139/80-89 mmHg is appropriate for this patient, applying the "as low as reasonably achievable" (ALARA) principle given her age, dizziness history, and multiple comorbidities. 2, 1 While guidelines recommend 120-129 mmHg systolic for most adults, a less aggressive target minimizes orthostatic symptoms in elderly patients with documented dizziness. 2, 1

Renal Function Considerations

ACE Inhibitor/ARB Use Decision

Do not restart losartan immediately—first establish BP control with amlodipine and reassess renal function. 3 However, if proteinuria is confirmed (ACR abnormal suggests this), an ACE inhibitor or ARB will be necessary for renoprotection. 3

The approach should be:

1. Week 0-2: Start amlodipine 5 mg daily alone 1
2. Week 2-4: Reassess BP, orthostatic symptoms, and check creatinine/potassium 3
3. Week 4-6: If BP remains >140/90 mmHg and patient tolerates amlodipine without dizziness, add low-dose ARB (losartan 25 mg daily, not PRN) 1, 3

Critical monitoring after adding ARB: Check serum creatinine and potassium within 2-4 weeks. 3 Continue the ARB unless creatinine rises >30% from baseline. 3

Avoiding Common Pitfalls

Never combine losartan with an ACE inhibitor—dual RAS blockade increases risks of hyperkalemia, acute kidney injury, and hypotension without additional benefit. 5 The VA NEPHRON-D trial demonstrated increased adverse events with combination therapy. 5

Monitor for NSAID use—coadministration with ARBs in elderly patients with compromised renal function can cause acute renal failure. 5 Ensure the patient avoids NSAIDs for knee pain management.

Breast Cancer Surveillance Considerations

Hypertension as Comorbidity

Hypertension is the most common comorbidity in breast cancer survivors (present in >60% of patients over 65 years). 2 The management plan must account for this chronic condition when considering any future cancer treatments. 2

No Bevacizumab Concerns

This patient is not on anti-VEGF therapy (bevacizumab), so the specific hypertension management protocols for those agents do not apply. 2 However, if future metastatic disease requires bevacizumab:

• BP must be <160/100 mmHg before initiating treatment 2
• ACE inhibitors/ARBs and dihydropyridine CCBs are preferred antihypertensives 2
• Close monitoring is mandatory as bevacizumab causes hypertension in 11-45% of patients 2

Knee Lump Assessment

The bilateral symmetrical medial knee lumps require imaging evaluation (ultrasound or MRI) to determine etiology before attributing symptoms solely to mechanical causes. The reduced walking distance may be multifactorial (knee pain, cardiovascular deconditioning, or claudication from vascular disease).

Ensure adequate pain control without NSAIDs given renal impairment and planned ARB therapy. 5 Consider acetaminophen or topical therapies as alternatives.

Monitoring Protocol

Initial 2-Week Follow-Up

Schedule reassessment within 2 weeks to evaluate: 1

• Orthostatic BP measurements (sitting and standing) 2, 1
• Symptom assessment: dizziness frequency and severity 1
• Home BP readings: Provide validated upper-arm device for home monitoring (three readings morning and evening for three consecutive days) 4
• Medication adherence: Emphasize daily dosing, not PRN 1

4-Week Laboratory Monitoring

Repeat blood tests: 3

• Serum creatinine and eGFR
• Serum potassium (especially important before adding ARB)
• Fasting glucose (previous value was abnormal)
• Quantified proteinuria (urine ACR)

Escalation Strategy if BP Not Controlled

If BP remains ≥140/90 mmHg on amlodipine 5 mg after 4 weeks and patient has no orthostatic symptoms: 1, 3

1. Add losartan 25 mg daily (not 50 mg initially given previous dizziness and renal impairment) 1, 5
2. Recheck creatinine/potassium in 2-4 weeks 3
3. If still uncontrolled after 4-6 weeks on dual therapy: Add indapamide 2.5 mg daily (thiazide-like diuretic preferred over hydrochlorothiazide in CKD) 1, 3

Referral threshold: Consider referral to hypertension specialist if BP remains ≥160/100 mmHg on three medications or if multiple drug intolerances develop. 2, 1

Patient Education Essentials

Explain gradual position changes to minimize orthostatic symptoms: sit at bedside for 1-2 minutes before standing, rise slowly from chairs. 1

Emphasize medication timing consistency: Take amlodipine at the same time daily (morning preferred to assess daytime BP control). 1

Home BP monitoring technique: Record readings with dates/times, bring log to appointments. 1, 4

Lifestyle modifications remain essential: 2

• Sodium restriction (<2 g/day) for both hypertension and CKD
• Weight management if BMI elevated
• Regular physical activity as tolerated by knee symptoms
• Smoking cessation if applicable

Special Considerations for Employment

The medical certificate request is appropriate given the need for frequent medical monitoring during this period of medication adjustment and the physical demands of caring for three grandchildren. 1 Uncontrolled hypertension with dizziness poses fall risk and requires stabilization before resuming employment activities.