What is the best initial hypertension (HTN) medication for an elderly female patient with hypercholesterolemia (high cholesterol) and reactive airway disease?

Recommended Initial Antihypertensive for Elderly Female with Hypercholesterolemia and Reactive Airway Disease

Start with a calcium channel blocker (amlodipine 5 mg daily) or an ACE inhibitor/ARB (lisinopril 10 mg daily or losartan 50 mg daily) as first-line therapy, avoiding beta-blockers entirely due to the reactive airway disease. 1

Primary Drug Selection Algorithm

First-Line: Calcium Channel Blocker

• Amlodipine 5-10 mg once daily is the safest initial choice for this patient because it effectively lowers blood pressure in elderly patients, has no adverse effects on reactive airway disease, does not worsen lipid profiles, and avoids the risk of first-dose hypotension seen with ACE inhibitors in elderly patients 1
• Calcium channel blockers (specifically dihydropyridines like amlodipine) have proven efficacy in isolated systolic hypertension trials in elderly patients and were used successfully as first-line therapy in multiple landmark trials 1

Alternative First-Line: ACE Inhibitor or ARB

• Lisinopril 10 mg daily or losartan 50 mg daily are acceptable alternatives, as they provide cardiovascular protection, do not adversely affect lipid metabolism, and are safe in reactive airway disease 1, 2, 3
• ACE inhibitors reduce left ventricular mass, cause no metabolic or lipid disturbances, have no adverse CNS effects, and carry low risk of orthostatic hypotension in elderly patients 3, 4
• Critical caveat: Start ACE inhibitors at the lowest effective dose in elderly patients and observe closely for 6 hours after the first dose due to risk of first-dose hypotension, which approaches 10% incidence in elderly patients 5

Drugs to Absolutely Avoid

Beta-Blockers Are Contraindicated

• Never use beta-blockers (including cardioselective agents like atenolol, metoprolol, or bisoprolol) as first-line therapy in this patient due to reactive airway disease 1
• Even cardioselective beta-blockers should be avoided in patients with bronchospastic airway disease unless there is a compelling indication like heart failure or coronary disease 1
• Non-cardioselective beta-blockers (nadolol, propranolol) are absolutely contraindicated in reactive airways disease 1

Blood Pressure Targets for Elderly Patients

• Target blood pressure <150/90 mmHg for patients ≥80 years old, with consideration for <140/90 mmHg if the patient is otherwise healthy and tolerates treatment well 1
• If the patient is 60-79 years old, target <140/90 mmHg per most international guidelines 1
• Achieve target blood pressure within 3 months of initiating treatment 2, 6

Combination Therapy Strategy if Monotherapy Fails

Step 2: Add Second Agent After 4-6 Weeks

• If starting with amlodipine and blood pressure remains uncontrolled, add lisinopril 10 mg daily or losartan 50 mg daily (creating the preferred combination of calcium channel blocker + ACE inhibitor or ARB) 1
• If starting with ACE inhibitor/ARB and blood pressure remains uncontrolled, add amlodipine 5 mg daily 1
• The combination of calcium channel blocker with ACE inhibitor or ARB is one of the most effective and well-tolerated two-drug combinations 1

Step 3: Add Thiazide Diuretic

• If blood pressure remains uncontrolled on two drugs, add a thiazide or thiazide-like diuretic (hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily) 1, 7
• This creates the preferred three-drug combination of ACE inhibitor/ARB + calcium channel blocker + diuretic 7

Critical Monitoring Parameters

Initial Monitoring (First 1-2 Weeks)

• Check blood pressure, serum creatinine, and potassium 1-2 weeks after initiating ACE inhibitor or ARB 2, 6
• Observe elderly patients closely for 6 hours after first dose of ACE inhibitor due to first-dose hypotension risk 5
• Monitor for signs of angioedema (tongue/throat swelling), which can occur even after years of ACE inhibitor use 8

Ongoing Monitoring

• Recheck blood pressure every 2-4 weeks until target is achieved 6
• Once controlled, follow up every 3-6 months 6
• Monitor renal function and electrolytes at each visit if on ACE inhibitor/ARB 2

Lipid Management Integration

• Continue statin therapy (atorvastatin) alongside antihypertensive treatment, as both hypertension and hypercholesterolemia are independent cardiovascular risk factors 2
• ACE inhibitors and calcium channel blockers have the advantage of causing no adverse effects on lipid metabolism, unlike thiazide diuretics and beta-blockers which can worsen lipid profiles 3

Common Pitfalls to Avoid

• Do not use beta-blockers as first-line therapy even if labeled "cardioselective"—reactive airway disease is a contraindication 1
• Do not start ACE inhibitors at high doses in elderly patients—begin with lowest effective dose (lisinopril 10 mg or less) to minimize first-dose hypotension risk 5
• Do not combine thiazide diuretic with beta-blocker as first-line therapy, as this combination has pronounced dysmetabolic effects and should be avoided in patients with hypercholesterolemia 1
• Initiate treatment gradually in uncomplicated elderly hypertensives rather than aggressively pursuing rapid blood pressure reduction 1