From the Guidelines
For a 59-year-old male with hypertension and heart failure who remains hypertensive (BP 150/100) despite being on Toprol ER 100 mg, spironolactone 50 mg daily, and Entresto 97-103, I would recommend adding amlodipine 5 mg daily. Amlodipine is a calcium channel blocker that works well in combination with the patient's current medications by providing additional vasodilation through a different mechanism. Start with 5 mg daily and consider titrating up to 10 mg daily if blood pressure remains elevated after 2-4 weeks. This medication can be taken with or without food, typically once daily. Common side effects include peripheral edema, headache, and flushing. Amlodipine is particularly appropriate because it's safe in heart failure patients, especially when they're already on optimal neurohormonal blockade as this patient is with beta-blocker, mineralocorticoid receptor antagonist, and angiotensin receptor-neprilysin inhibitor therapy. The addition of a dihydropyridine calcium channel blocker provides complementary action by blocking calcium influx into vascular smooth muscle cells, resulting in arterial vasodilation without significant negative inotropic effects that could worsen heart failure. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, the recommended treatment of resistant hypertension includes the addition of further diuretic therapy or other agents, but the most recent and highest quality study does not specifically address the addition of amlodipine in this context. However, the 2020 International Society of Hypertension global hypertension practice guidelines 1 suggest considering the addition of a dihydropyridine calcium channel blocker (DHP-CCB) in certain cases, and the 2007 guidelines for the management of arterial hypertension 1 indicate that calcium antagonists can be beneficial in patients with coronary heart disease and heart failure.
Key Considerations
- The patient's current medications, including Toprol ER, spironolactone, and Entresto, are optimized for heart failure management.
- The addition of amlodipine provides a complementary mechanism of action to reduce blood pressure without negatively impacting heart failure treatment.
- Monitoring for potential side effects, such as peripheral edema, headache, and flushing, is necessary.
- The patient's blood pressure should be closely monitored, and the dose of amlodipine may need to be adjusted based on the response to treatment.
Potential Alternatives
- Other calcium channel blockers, such as verapamil, could be considered, but amlodipine is generally better tolerated and has a more favorable side effect profile.
- The addition of other agents, such as bisoprolol or doxazosin, may be considered if the patient's blood pressure remains uncontrolled despite the addition of amlodipine, as suggested by the 2024 ESC guidelines 1.
From the FDA Drug Label
1 INDICATIONS & USAGE 1. 1 Hypertension Amlodipine besylate tablets is indicated for the treatment of hypertension, to lower blood pressure.
Many patients will require more than one drug to achieve blood pressure goals. Amlodipine besylate tablets may be used alone or in combination with other antihypertensive agents.
The patient is currently on Toprol ER 100 mg, spironolactone 50 mg daily, and entresto 97-103 with a blood pressure of 150/100. Amlodipine could be added to improve blood pressure control, as it is indicated for the treatment of hypertension and can be used in combination with other antihypertensive agents 2. Key considerations for adding amlodipine include:
- Starting with a low dose, such as 2.5 mg or 5 mg once daily, and titrating as needed to achieve blood pressure goals 2
- Monitoring for potential drug interactions, such as with beta-blockers, and adjusting the dose accordingly 2
From the Research
Potential Additions to Improve Blood Pressure
Given the patient's current medication regimen, which includes Toprol ER 100 mg, spironolactone 50 mg daily, and entresto 97-103, with a blood pressure of 150/100, several options could be considered to improve blood pressure control:
- Adding a calcium channel blocker (CCB) could be beneficial, as studies have shown that CCBs can effectively lower blood pressure, especially when used in combination with other drugs 3.
- Considering a thiazide diuretic, such as hydrochlorothiazide, as an add-on therapy, as it is often recommended in combination with a renin-angiotensin system blocker for treating hypertension, particularly in patients with renal disease 4.
- Evaluating the potential for a fixed-dose combination of an angiotensin II receptor blocker, a calcium channel blocker, and a thiazide diuretic, which has been shown to improve blood pressure control and aid compliance with long-term therapy 5.
Considerations for Treatment
When selecting an additional medication, it is essential to consider the patient's individual needs and potential interactions with their current medications:
- The choice between a CCB and a thiazide diuretic may depend on the patient's specific condition, such as renal disease, and the potential side effects of each medication 4, 3.
- The use of fixed-dose combinations can simplify treatment regimens and improve adherence, but it is crucial to carefully evaluate the patient's response to the new medication and adjust as needed 5, 6.
Evidence-Based Recommendations
Recent guidelines and studies support the use of combination therapy to achieve optimal blood pressure control:
- The JAMA review recommends first-line therapy with a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker, titrated to achieve a target blood pressure of <130/80 mm Hg 7.
- The European hypertension guidelines suggest combining angiotensin II receptor blockers or angiotensin-converting enzyme inhibitors with calcium channel blockers and/or thiazide diuretics to improve blood pressure control 5.