What is the next step for a patient with uncontrolled hypertension (blood pressure 140/88) on eplerenone (25 mg) and telmisartan (80 mg) daily?

Uncontrolled Hypertension Management

The next step is to increase eplerenone from 25 mg to 50 mg once daily, as the patient is currently on a subtherapeutic dose and has not yet reached the target dose for hypertension treatment. 1

Current Situation Analysis

Your patient has a blood pressure of 140/88 mmHg on:

• Telmisartan 80 mg daily (maximum dose for hypertension) 2
• Eplerenone 25 mg daily (starting dose, not target dose) 1

This represents inadequately controlled hypertension, as the target BP should be <130/80 mmHg for most adults. 3

Recommended Treatment Escalation

Step 1: Optimize Current Medications

Increase eplerenone to 50 mg once daily. 1

• The FDA-approved dosing for eplerenone in hypertension is 50 mg once daily, with the option to increase to 50 mg twice daily if needed 1
• Your patient is currently on only 25 mg daily, which is the starting dose 1
• This dose escalation should be done with monitoring of serum potassium and renal function before and after the increase 1

Step 2: If BP Remains Uncontrolled After Eplerenone Optimization

If blood pressure remains above target after 4 weeks on eplerenone 50 mg daily, add a calcium channel blocker (CCB) such as amlodipine 5-10 mg daily. 3, 4

• The 2024 ESC guidelines recommend adding additional agents from different classes when BP is not controlled on a three-drug combination 3
• A CCB is the logical next step as the patient is already on an ARB and mineralocorticoid receptor antagonist 3

Step 3: Alternative if CCB Not Tolerated

If a CCB is not suitable or tolerated, add a thiazide-like diuretic such as chlorthalidone 12.5-25 mg once daily or indapamide 1.5 mg. 3, 4

Monitoring Requirements

Check serum potassium and creatinine:

• Before increasing eplerenone dose 1
• 1 week after dose increase 3
• 4 weeks after dose increase 3
• Then at 1,2,3, and 6 months, and every 6 months thereafter 3

Potassium management: 3

• If potassium rises to >5.5 mmol/L: halve the eplerenone dose
• If potassium rises to ≥6.0 mmol/L: stop eplerenone immediately

Renal function monitoring: 3

• If creatinine rises to >220 µmol/L (2.5 mg/dL): halve the eplerenone dose
• If creatinine rises to >310 µmol/L (3.5 mg/dL): stop eplerenone immediately

Blood Pressure Targets

Target BP: <130/80 mmHg 3

• The 2024 ESC guidelines recommend that treated systolic BP should be targeted to 120-129 mmHg in most adults, provided treatment is well tolerated 3
• Diastolic BP target is <80 mmHg for all hypertensive patients 3
• This target should be achieved within 3 months of treatment adjustment 3

When to Refer to Specialist

Consider referral to a hypertension specialist if: 4, 5

• BP remains uncontrolled despite optimization of eplerenone and addition of a fourth agent
• Suspected secondary causes of hypertension
• Development of resistant hypertension (uncontrolled BP on three or more medications including a diuretic at optimal doses)

Important Caveats

Do not combine telmisartan with an ACE inhibitor - the patient is already on an ARB (telmisartan), and dual renin-angiotensin system blockade is not recommended. 3

Ensure medication adherence - confirm the patient is actually taking medications as prescribed before escalating therapy. 3, 5

Lifestyle modifications - ensure concurrent implementation of sodium restriction (<2,300 mg/day), regular aerobic exercise (≥150 min/week), weight management if overweight, and alcohol moderation. 3