How to manage Hypertension in a patient taking Lisinopril-Hydrochlorothiazide and Metoprolol Tartrate with a blood pressure of 136/98?

Management of Uncontrolled Hypertension on Triple Therapy

This patient requires immediate intensification of antihypertensive therapy by adding a calcium channel blocker (amlodipine 5-10 mg daily) to create an optimal triple combination of ACE inhibitor, thiazide diuretic, and CCB, as the current regimen of lisinopril-HCTZ plus metoprolol is suboptimal. 1

Current Regimen Assessment

The patient is on lisinopril 20 mg/HCTZ 12.5 mg plus metoprolol tartrate 25 mg twice daily with a BP of 136/98 mmHg, indicating inadequate control (target <130/80 mmHg). 1 This regimen is problematic because:

• Beta-blockers are not first-line agents for hypertension and should only be combined with other major BP-lowering drug classes when there are compelling indications such as angina, post-MI, heart failure with reduced ejection fraction, or heart rate control. 1
• The patient appears to have COPD (on Trelegy Ellipta and albuterol), making beta-blocker use potentially problematic for respiratory symptoms. 1
• The preferred triple combination is RAS blocker + CCB + thiazide diuretic, not RAS blocker + thiazide + beta-blocker. 1

Recommended Treatment Algorithm

Step 1: Add Calcium Channel Blocker

Add amlodipine 5 mg daily initially, titrating to 10 mg if needed to create the guideline-recommended triple therapy of ACE inhibitor + thiazide diuretic + dihydropyridine CCB. 1, 2 This combination:

• Is the preferred three-drug regimen with strongest evidence for BP control and cardiovascular outcomes. 1
• Should preferably be given as a single-pill combination to improve adherence. 1

Step 2: Reassess Beta-Blocker Need

Consider discontinuing or tapering metoprolol unless there is a compelling indication (history of MI, heart failure, or symptomatic tachycardia). 1 The patient has:

• Respiratory disease (COPD) where beta-blockers may worsen bronchospasm. 1
• No clear indication listed for beta-blocker therapy in the medication list.
• Metoprolol tartrate at low dose (25 mg BID), which is unlikely providing significant BP benefit. 1

Step 3: Optimize Diuretic Dosing

The current HCTZ dose of 12.5 mg is appropriate as initial therapy, but if BP remains uncontrolled after adding CCB, consider increasing HCTZ to 25 mg or switching to a thiazide-like diuretic (chlorthalidone or indapamide) which have superior efficacy. 1

Target Blood Pressure

Target BP is <130/80 mmHg for this patient. 1 The current BP of 136/98 mmHg represents Grade 1 hypertension requiring immediate treatment intensification. 1

If BP Remains Uncontrolled on Optimal Triple Therapy

Fourth-Line Agent

Add spironolactone 25 mg daily if BP remains ≥140/90 mmHg after 3 months on optimal triple therapy (lisinopril + HCTZ + amlodipine at maximum tolerated doses). 1, 2 This requires:

• Serum potassium <4.5 mmol/L
• eGFR >45 mL/min/1.73m²
• Monitor potassium and renal function within 1-2 weeks. 1, 2

Alternative Fourth-Line Agents

If spironolactone is contraindicated or not tolerated, consider: 1

• Eplerenone (alternative aldosterone antagonist)
• Doxazosin (alpha-blocker)
• Amiloride (potassium-sparing diuretic)
• Clonidine (centrally acting agent)

Monitoring Plan

• Recheck BP within 2-4 weeks after adding amlodipine to assess response. 2
• Monitor electrolytes (potassium) within 1-2 weeks of any medication changes, especially if adding or increasing diuretics. 2
• Achieve target BP within 3 months of treatment intensification. 1
• Consider home BP monitoring to confirm office readings and assess for white coat effect (target home BP <135/85 mmHg). 1

Critical Pitfalls to Avoid

• Do not use non-dihydropyridine CCBs (diltiazem, verapamil) as they can worsen respiratory function and are less effective for BP control in combination therapy. 1, 2
• Do not combine two RAS blockers (ACE inhibitor + ARB) - this is contraindicated. 1
• Avoid inadequate diuretic dosing - this is a common cause of apparent resistant hypertension. 1, 2
• Do not lower BP too rapidly - titrate medications gradually to avoid orthostatic hypotension, especially given patient's age and multiple medications. 2
• Assess medication adherence before labeling as resistant hypertension - complex regimens reduce adherence. 1

Special Considerations for This Patient

• COPD/Asthma: The patient is on Trelegy Ellipta and albuterol, suggesting significant respiratory disease. Dihydropyridine CCBs are safe, but beta-blockers should be avoided or used with extreme caution. 1
• Polypharmacy: Patient is on 9 medications. Strongly consider single-pill combinations to reduce pill burden and improve adherence. 1
• Hypothyroidism: Ensure levothyroxine dose is optimized, as hypothyroidism can contribute to hypertension. 1