How to manage a patient with hypertension, taking nifedipine (calcium channel blocker) 90 mg Extended Release (ER), sildenafil (phosphodiesterase type 5 inhibitor) 50 mg, hydralazine (vasodilator) 50 mg three times a day (tid), and omeprazole (proton pump inhibitor) 40 mg, presenting with dizziness, blurry vision, lightheadedness, and severe gingival swelling, potentially related to nifedipine use?

Immediate Management: Switch from Nifedipine to Alternative Antihypertensive

This patient requires immediate discontinuation of nifedipine due to severe drug-induced gingival hyperplasia that is preventing necessary dental care, and their acute symptoms (dizziness, blurry vision, lightheadedness) suggest possible hypotension from excessive vasodilation with their current multi-drug regimen. 1

Acute Assessment (Today's Visit)

Check Blood Pressure Immediately

• Measure BP in both sitting and standing positions to assess for orthostatic hypotension 2
• The combination of nifedipine 90 mg ER + hydralazine 150 mg/day + sildenafil 50 mg creates substantial vasodilatory burden 2
• Dizziness, blurry vision, and lightheadedness strongly suggest symptomatic hypotension or excessive BP lowering 2

If BP is Low or Patient is Symptomatic from Hypotension:

• Hold today's doses of nifedipine and hydralazine 2
• Provide IV fluids if significantly hypotensive
• Observe until symptoms resolve and BP stabilizes

If BP Remains Elevated (≥140/90 mmHg):

• This represents resistant hypertension on a three-drug regimen requiring medication optimization 2

Medication Restructuring Plan

Step 1: Discontinue Nifedipine Permanently

• Gingival hyperplasia is a well-documented adverse effect of nifedipine, occurring in up to 29% of patients on 90 mg daily 1
• This side effect is preventing essential dental procedures and will not resolve until the drug is stopped 1
• The 3-4 month duration indicates established tissue changes requiring drug cessation

Step 2: Optimize to Guideline-Recommended Triple Therapy

Replace current regimen with: 2

First-line triple combination (single-pill if available):

• ACE inhibitor or ARB (e.g., lisinopril 20-40 mg daily OR losartan 50-100 mg daily)
• Thiazide-like diuretic (chlorthalidone 12.5-25 mg daily preferred over hydrochlorothiazide) 2
• Alternative CCB without gingival effects: amlodipine 5-10 mg daily (lower gingival hyperplasia risk than nifedipine) 2

Discontinue hydralazine - this is a 5th-6th line agent that should only be used after spironolactone, beta-blockers, and other options have failed 2

Step 3: If BP Remains Uncontrolled on Optimized Triple Therapy

Add spironolactone 25-50 mg daily as the preferred 4th agent for resistant hypertension 2

If spironolactone is not tolerated:

• Eplerenone 50-200 mg daily (may need twice-daily dosing) 2
• OR vasodilating beta-blocker (carvedilol, labetalol, or nebivolol) 2

Only after these fail, consider adding back hydralazine 25 mg TID, titrating to 50 mg TID 2

Sildenafil Consideration

• Sildenafil 50 mg causes vasodilation and can contribute to hypotensive symptoms 2
• Counsel patient to avoid taking sildenafil within 24 hours of symptomatic episodes
• Consider dose reduction to 25 mg if symptoms persist after BP medication adjustment

Dental Referral

• Inform dentist that nifedipine has been discontinued 1
• Gingival hyperplasia typically improves over 1-3 months after drug cessation, though surgical intervention may be needed for severe cases 1
• Schedule dental follow-up in 4-6 weeks to reassess gingival status

Follow-Up Timeline

• Recheck BP in 1 week after medication changes 2
• Assess for resolution of dizziness, blurry vision, and lightheadedness
• Monthly visits until BP is controlled at target 120-129 mmHg systolic 2
• Once stable, transition to at least annual BP monitoring 2

Key Pitfalls to Avoid

• Do not use rapid-acting nifedipine for any BP management - associated with adverse outcomes including hypotension, MI, and stroke 2, 3
• Do not continue hydralazine as a 3rd-line agent when guideline-recommended options (RAS blocker + CCB + diuretic) have not been tried 2
• Do not assume resistant hypertension without first optimizing to appropriate triple therapy and assessing medication adherence 2
• Avoid combining two RAS blockers (ACE inhibitor + ARB) - this is not recommended 2