How to manage a patient with hypertension and a history of poor medication compliance, currently on felodipine and atorvastatin, with elevated blood pressure and previous erectile dysfunction on metoprolol?

Management of Hypertension with Poor Compliance

Address medication adherence immediately as the primary cause of this patient's uncontrolled blood pressure (144/90 mmHg), then intensify therapy by adding a thiazide-like diuretic to the current felodipine regimen, while continuing atorvastatin and avoiding beta-blockers given the history of erectile dysfunction. 1

Immediate Priority: Verify and Address Compliance

The most critical first step is confirming medication adherence, as poor compliance is the most common cause of apparent resistant hypertension and increases cardiovascular risk. 1, 2

• Directly discuss the patient's erratic compliance from last month—physicians often overestimate patient adherence and fail to ask about compliance, leading to inappropriate treatment intensification when the real issue is non-adherence. 1

• The asymptomatic nature of hypertension is a major barrier to compliance; patients lack immediate consequences when modifying doses, making them more likely to discontinue or skip medications. 1

• Adverse effects significantly increase non-compliance—this patient previously stopped metoprolol due to erectile dysfunction, demonstrating how side effects drive treatment discontinuation. 1, 3

• Consider electronic monitoring or pill counts if available, as objective compliance monitoring can markedly decrease blood pressure (from 159/104 to 143/92 mmHg in studies) without any medication changes. 4, 5

Medication Optimization Strategy

Current Regimen Analysis

• Felodipine 5mg once daily is appropriate as a dihydropyridine calcium channel blocker (DHP-CCB), providing 24-hour coverage with trough concentrations maintaining antihypertensive effect. 6

• The patient tolerates felodipine well (no finger swelling/edema), which is crucial for long-term adherence. 1, 6

• Atorvastatin 20mg should be continued for cardiovascular risk reduction. 1

Treatment Intensification

Add a thiazide-like diuretic as the next step, following the ISH 2020 guideline algorithm for non-Black patients: ACEI/ARB or DHP-CCB → increase to full dose → add thiazide/thiazide-like diuretic. 1, 2

• First, increase felodipine to 10mg once daily (full dose) before adding additional agents, as the current 5mg dose may be subtherapeutic. 1, 6

• If BP remains elevated after 2-4 weeks on felodipine 10mg, add chlorthalidone 12.5-25mg daily or indapamide 1.25-2.5mg daily as preferred thiazide-like diuretics. 1, 2

• Simplify the regimen with once-daily dosing to enhance compliance—felodipine's extended-release formulation maintains therapeutic levels for 24 hours, protecting against occasional missed doses. 1, 6, 5

Avoid Beta-Blockers

• Do not restart metoprolol or any beta-blocker given the documented erectile dysfunction, which is a major compliance barrier and quality-of-life issue. 1, 3

• Beta-blockers are not first-line for uncomplicated hypertension unless there are specific indications (prior MI, heart failure, angina)—none are present in this patient. 1, 2

Blood Pressure Targets and Monitoring

Target BP <140/90 mmHg initially, with a goal of reducing BP by at least 20/10 mmHg within 3 months. 1

• The current BP of 144/90 mmHg is only 4 mmHg above target systolic, suggesting modest intensification may achieve control. 1

• Reassess BP every 2-4 weeks after medication changes to achieve target within 3 months. 1, 2

• Consider home BP monitoring to confirm hypertension (target <135/85 mmHg at home) and rule out white coat effect. 1, 2

Laboratory Monitoring

• Recheck renal function and electrolytes 2-4 weeks after adding a diuretic, particularly monitoring potassium and creatinine. 2

• The current eGFR of 89 mL/min/1.73m² and normal renal function support safe use of thiazide-like diuretics. 1

• The elevated uric acid (0.50 mmol/L) may worsen with thiazide diuretics but is not a contraindication; monitor for gout symptoms. 6

Compliance Enhancement Strategies

Prescribe once-daily, long-acting medications and address cost/side effect barriers directly with the patient. 3, 7, 5

• Use fixed-dose combination pills if available (e.g., felodipine/diuretic combination) to reduce pill burden and improve adherence. 7

• Schedule regular follow-up appointments (every 2-4 weeks initially) as patients who rapidly achieve target BP show increased persistence with therapy. 1

• Educate the patient on cardiovascular risks of uncontrolled hypertension and the importance of lifelong treatment, as lack of understanding contributes to non-compliance. 1, 3

Common Pitfalls to Avoid

• Do not assume medication ineffectiveness when BP is uncontrolled—verify compliance first before adding or switching agents, as physicians frequently misinterpret non-compliance as treatment failure. 1

• Do not prescribe medications with known side effects that caused previous discontinuation (e.g., beta-blockers causing erectile dysfunction in this patient). 1, 3

• Avoid NSAIDs if possible, as they blunt antihypertensive effects and can worsen BP control. 2

• Do not over-intensify therapy too quickly—allow 2-4 weeks to assess response to each medication adjustment. 1, 2

Referral Criteria

Refer to a hypertension specialist if BP remains uncontrolled despite three antihypertensive agents at optimal doses with confirmed adherence. 2

• Consider screening for secondary hypertension (sleep apnea, primary aldosteronism, renal artery stenosis) if resistant hypertension develops. 2