What is the diagnosis and plan of care for a patient with hypertension, low vitamin D, and hyperlipidemia, who has had adverse reactions to amlodipine and lisinopril?

Diagnosis and Treatment Plan for Hypertension with Hyperlipidemia

Primary Diagnoses

This patient has stage 2 hypertension (162/100 mmHg), hyperlipidemia (total cholesterol 238 mg/dL, LDL 154.4 mg/dL), and vitamin D insufficiency (27 ng/mL). 1

• Stage 2 hypertension requires immediate pharmacological intervention as BP ≥160/100 mmHg 1
• Hyperlipidemia with LDL >130 mg/dL necessitates statin therapy for cardiovascular risk reduction 1
• Vitamin D insufficiency (normal >30 ng/dL) requires supplementation
• Mildly elevated calcium (10.6 mg/dL, upper limit typically 10.5) and albumin (5.1 g/dL) may suggest dehydration or require monitoring

Antihypertensive Treatment Algorithm (Avoiding Amlodipine and Lisinopril)

Step 1: Initial Antihypertensive Therapy

Start with an angiotensin receptor blocker (ARB) as first-line therapy since ACE inhibitors (lisinopril) caused adverse reactions. 1

• Losartan 50 mg once daily or valsartan 80 mg once daily are appropriate ARB alternatives 1
• ARBs provide similar cardiovascular protection to ACE inhibitors without the cough or angioedema risk 1
• Target BP <130/80 mmHg given the cardiovascular risk profile 1

Step 2: Add Thiazide Diuretic if Monotherapy Insufficient

If BP remains >130/80 mmHg after 2-4 weeks, add chlorthalidone 12.5-25 mg once daily. 1

• Thiazide diuretics are highly effective as second-line agents and reduce cardiovascular events 1
• Chlorthalidone is preferred over hydrochlorothiazide for superior BP reduction and longer duration of action 1
• Monitor potassium levels given baseline potassium not provided and risk of hypokalemia 1

Step 3: Third-Line Agent if Needed

If BP control inadequate with ARB + thiazide, add a beta-blocker (metoprolol succinate 50-100 mg daily or carvedilol 6.25-25 mg twice daily). 1

• Avoid non-selective beta-blockers in metabolic syndrome due to adverse metabolic effects 1
• Carvedilol and nebivolol have vasodilating properties with less metabolic impact 1
• Alternative: hydralazine 25-50 mg twice daily if beta-blockers contraindicated 1

Step 4: Resistant Hypertension Management

If BP remains uncontrolled on three agents, add spironolactone 25 mg daily. 1, 2

• Mineralocorticoid receptor antagonists are highly effective in resistant hypertension 1, 2
• Monitor potassium and renal function closely when combining with ARB 1
• Consider secondary hypertension evaluation if truly resistant 1, 3

Lipid Management

Initiate atorvastatin 40 mg daily or rosuvastatin 20 mg daily to achieve LDL <100 mg/dL (ideally <70 mg/dL given hypertension). 1

• High-intensity statin therapy reduces cardiovascular events by 25-30% 1
• Target LDL reduction of 30% or to <100 mg/dL, whichever achieves greater reduction 1
• Recheck lipid panel in 6-8 weeks to assess response 1

Vitamin D Supplementation

Prescribe vitamin D3 2000-4000 IU daily to achieve levels >30 ng/mL.

• Recheck vitamin D level in 3 months
• Higher doses may be needed initially if absorption issues suspected

Lifestyle Modifications

Implement DASH diet with sodium restriction to <2300 mg daily (ideally <1500 mg), weight loss if BMI >25, and aerobic exercise 150 minutes weekly. 1

• Sodium restriction alone can reduce BP by 5-10 mmHg 1
• Weight loss of 10 kg reduces BP by approximately 5-20 mmHg 1
• Limit alcohol to ≤2 drinks daily for men 1

Monitoring Schedule

Recheck BP in 2 weeks after initiating therapy, then monthly until target achieved, then every 3-6 months. 1

• Measure BP at both peak (6 hours post-dose) and trough (24 hours post-dose) initially 4
• Recheck basic metabolic panel in 2-4 weeks after starting ARB and diuretic 1
• Annual lipid panel, renal function, and electrolytes once stable 1
• Consider home BP monitoring for accurate assessment 1

Critical Pitfalls to Avoid

Do not use alpha-blockers (doxazosin, prazosin) as they increase heart failure risk and are less effective than other antihypertensives. 1

Avoid moxonidine and centrally-acting agents due to increased mortality risk in cardiovascular disease. 1

Do not use non-dihydropyridine calcium channel blockers (diltiazem, verapamil) if any evidence of heart failure. 1

Monitor for hyperkalemia when combining ARB with spironolactone or other potassium-sparing agents. 1