From the Guidelines
If your blood pressure remains high despite taking amlodipine, metoprolol, lisinopril, and a thiazide diuretic, the most effective next step would be to add a low dose of spironolactone as the 4th line agent, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. This approach is supported by the latest evidence, which suggests that spironolactone can be beneficial in achieving blood pressure targets in patients with resistant hypertension. Key considerations include:
- Ensuring serum potassium is <4.5 mmol/L and eGFR is >45 ml/min/1.73m2 before initiating spironolactone 1
- Optimizing the current treatment regimen, including health behavior change and diuretic-based treatment, with maximally tolerated doses of diuretics and optimal choice of diuretic 1
- Investigating potential causes of resistant hypertension, such as medication adherence issues, white coat hypertension, secondary causes, and lifestyle factors 1
- Considering alternative options, such as eplerenone, amiloride, bisoprolol, or doxazosin, if spironolactone is contraindicated or not tolerated 1 It is essential to consult a healthcare provider for a comprehensive evaluation and to determine the best course of action for managing resistant hypertension.
From the Research
High Blood Pressure Despite Medication
- The patient is taking amlodipine, metoprolol, and lisinopril, as well as thiazides, but still experiencing high blood pressure 2, 3, 4, 5, 6.
Definition of Resistant Hypertension
- Resistant hypertension is defined as high blood pressure that requires three or more medications for adequate control, or controlled blood pressure that requires four or more medications 2.
Treatment of Resistant Hypertension
- The treatment of resistant hypertension includes pharmacologic treatments, such as thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) 3.
- ACEIs and ARBs should not be used simultaneously, and at least one agent should be a thiazide diuretic or a calcium channel blocker in black patients 3.
Effectiveness of Amlodipine and Metoprolol
- Amlodipine has been shown to reduce blood pressure variability and successfully lower blood pressure, and is a wise choice for older adults due to its ability to control blood pressure and protect against stroke and myocardial infarction 4.
- However, treatment with metoprolol and amlodipine did not result in a drop in blood pressure compared to no treatment in patients with severe inpatient hypertension 5.
Comparison of Amlodipine Plus Bisoprolol or Plus Valsartan
- The clinical outcomes in patients treated with amlodipine plus bisoprolol (A + B) or amlodipine plus valsartan (A + V) were similar regarding all-cause death, atherosclerotic cardiovascular disease event, and heart failure, but the risk of hemorrhagic stroke was lower in the A + B group 6.