How can medication be optimized for a patient with ESRD, DM2, HTN, HLD, seizure disorder, and HFpEF on HD with volume overload and elevated blood pressure?

Medication Optimization for ESRD Patient on HD with Uncontrolled Hypertension and HFpEF

Blood Pressure Management - Immediate Actions

Your patient's BP of 160s systolic requires immediate optimization, with a target of <130/80 mmHg, achieved through volume control as the primary intervention and medication adjustments as secondary measures. 1

Volume Status Assessment (Priority #1)

• Reassess dry weight immediately - volume overload is the most common cause of uncontrolled hypertension in HD patients and must be addressed before escalating antihypertensive medications 1
• Optimize ultrafiltration during dialysis sessions to achieve euvolemia 1
• Counsel on strict sodium restriction to ≤5g sodium chloride (2.0g sodium) daily 1
• Consider switching from thiazide-type diuretics to loop diuretics given ESRD - in patients with severe renal impairment, loop diuretics are necessary as thiazides lose efficacy 2

Antihypertensive Medication Adjustments

Current regimen issues:

• Losartan 25mg BID is suboptimal - increase to 50mg daily initially, then titrate to 100mg daily based on BP response 3
• Hydralazine 50mg TID is appropriate for HFpEF in combination with other agents 1
• Carvedilol 25mg BID and amlodipine 10mg daily are at appropriate doses 1

Specific medication changes:

1. Increase losartan from 25mg BID to 50mg once daily, then titrate to 100mg daily - the current dose is below the recommended starting dose of 50mg for hypertension 3

2. Add spironolactone 25mg daily for resistant hypertension - this provides substantial mortality benefit (NNT of 6 over 36 months) in HF and is specifically recommended for resistant hypertension 1, 4

   • Monitor potassium closely given concurrent ARB use
   • Do not use if serum creatinine ≥2.5 mg/dL in men or ≥2.0 mg/dL in women, or if potassium ≥5.0 mEq/L 1

3. Add SGLT2 inhibitor (empagliflozin 10mg or dapagliflozin 10mg daily) - provides mortality and morbidity benefits in HFpEF beyond BP reduction, with Class I recommendation 1, 4

   • Contraindicated if eGFR <20 mL/min/1.73m², but can be considered in HD patients for cardiovascular benefits 1

Diabetes Management

Current glycemic control (78-235 mg/dL) is inadequate with Januvia 25mg daily alone.

Medication optimization:

1. Continue Januvia (sitagliptin) 25mg daily - appropriate dose for ESRD (normal dose is 100mg, reduced to 25mg for dialysis patients) 1

2. Add empagliflozin or dapagliflozin as recommended above - provides dual benefit for both HFpEF and diabetes with cardiovascular mortality reduction 1

   • Empagliflozin is specifically recommended to reduce risk of death in T2DM with CVD 1

3. Consider adding GLP-1 receptor agonist (liraglutide, semaglutide, or dulaglutide) if glycemic control remains inadequate - these reduce CV events and mortality in T2DM patients 1

4. Avoid saxagliptin - not recommended in patients with high risk of HF 1

HFpEF-Specific Management

For HFpEF with persistent hypertension after volume management:

1. Current beta-blocker (carvedilol 25mg BID) is appropriate - provides 14-35% mortality reduction and should be continued 1, 4

2. Ensure ACE inhibitor/ARB is optimized - increase losartan to 100mg daily as noted above 1

3. SGLT2 inhibitor addition is Class I recommendation for symptomatic HFpEF to improve outcomes 1, 4

Medications to Avoid

Do not add or continue:

• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) - negative inotropic effects worsen HF 1, 4
• Alpha-blockers (doxazosin) - 2.04-fold increased HF risk 1, 4
• Clonidine or moxonidine - increased mortality in HF 1, 4
• Aliskiren - increased adverse events when combined with ARBs 1, 4
• Thiazolidinediones (pioglitazone, rosiglitazone) - contraindicated in HF 1

Monitoring Requirements

Essential monitoring parameters:

• Potassium and creatinine before and after adding spironolactone (weekly initially, then monthly) 1, 4
• Standing BP to assess orthostatic hypotension 4
• Pre- and post-dialysis weights to optimize dry weight 1
• HbA1c every 3 months to assess glycemic control 5
• Volume status assessment at each dialysis session 1

Implementation Timeline

Week 1:

• Reassess and reduce dry weight by 1-2 kg if volume overloaded
• Increase losartan to 50mg daily
• Add empagliflozin 10mg daily

Week 2-4:

• Check potassium and creatinine
• If BP remains >130 systolic and potassium <5.0 mEq/L, add spironolactone 25mg daily
• Titrate losartan to 100mg daily if tolerated

Week 4-8:

• Reassess BP control
• If HbA1c remains >7%, consider adding GLP-1 receptor agonist
• Continue optimizing dry weight through dialysis

Target BP: <130/80 mmHg 1