What is the management approach for a patient with hypertension and a metallic taste, specifically a copper taste?

Management of Hypertension with Metallic (Copper) Taste

This patient requires immediate evaluation for secondary hypertension, specifically screening for Wilson's disease and primary aldosteronism, while simultaneously initiating standard hypertensive workup and treatment. The metallic taste is a red flag symptom that warrants investigation beyond routine hypertension management 1.

Immediate Diagnostic Workup

Screen for secondary causes of hypertension given the presence of an unusual symptom (metallic taste):

• Measure serum ceruloplasmin and 24-hour urinary copper excretion to evaluate for Wilson's disease, a rare but treatable cause of hypertension that can present with copper taste due to copper accumulation 1
• Obtain serum aldosterone-to-renin ratio to screen for primary aldosteronism, which affects approximately 10% of hypertensive patients and can present with resistant hypertension 1
• Complete basic hypertension workup: serum creatinine, eGFR, urine albumin-to-creatinine ratio (ACR), serum sodium and potassium, TSH, and 12-lead ECG 1
• Perform fundoscopy if BP >180/110 mmHg to evaluate for hypertensive emergency and malignant hypertension 1

Confirm Hypertension Diagnosis

Use out-of-office blood pressure monitoring before initiating treatment if BP is 140-159/90-99 mmHg:

• Ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) is recommended to confirm diagnosis and exclude white coat hypertension 1, 2
• If BP ≥160/100 mmHg, confirm within 1 month preferably with home or ambulatory measurements 1
• If BP ≥180/110 mmHg, immediately exclude hypertensive emergency (assess for acute end-organ damage including encephalopathy, acute renal failure, retinal hemorrhages/papilledema, acute heart failure) 1, 3

Rule Out Drug-Induced Hypertension

Obtain detailed medication and substance history:

• Ask specifically about: NSAIDs, oral contraceptives, steroids, decongestants (nasal drops), cyclosporine, tacrolimus, erythropoietin, licorice consumption, cocaine, amphetamines, and alcohol use 1
• These substances can cause or worsen hypertension and must be discontinued or modified before attributing hypertension to other causes 1

Initial Pharmacological Treatment

Initiate first-line antihypertensive therapy targeting BP <130/80 mmHg:

• Start with ACE inhibitor (e.g., enalapril) or ARB (e.g., candesartan), thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide), or dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 4, 5
• Consider single-pill combination therapy to improve adherence 6, 2
• Target BP <130/80 mmHg for adults <65 years 2, 5

Lifestyle Modifications (Concurrent with Medication)

Implement evidence-based lifestyle interventions immediately:

• Restrict sodium to approximately 2 g/day (equivalent to 5 g salt/day or one teaspoon) by avoiding processed foods and not adding salt at the table 1, 2
• Prescribe 150 minutes/week of moderate-intensity aerobic exercise (30 minutes, 5-7 days/week) supplemented with resistance training 2-3 times/week 1
• Target BMI 20-25 kg/m² and waist circumference <94 cm (men) or <80 cm (women) 1
• Limit alcohol to <100 g/week (preferably avoid completely for best outcomes) 1
• Adopt Mediterranean or DASH diet (high in fruits, vegetables, low-fat dairy, reduced saturated fat) 1, 2

Follow-Up and Monitoring

Establish structured follow-up protocol:

• Monitor BP every 2-4 weeks during titration phase until target achieved 1, 2
• Check serum potassium and creatinine 2-4 weeks after starting ACE inhibitor, ARB, or diuretic 2
• Reassess at 3 months to ensure BP control and evaluate response to lifestyle modifications 1, 2
• If secondary hypertension is confirmed, refer to specialist center with appropriate expertise 1

Critical Pitfalls to Avoid

Common errors that compromise outcomes:

• Do not dismiss the metallic taste as insignificant—it may indicate Wilson's disease or other metabolic disorders requiring specific treatment beyond standard hypertension management 1
• Do not use immediate-release nifedipine, hydralazine, or nitroglycerin for hypertensive urgencies—these cause unpredictable BP drops and are associated with adverse outcomes 3
• Do not attribute treatment failure to "resistant hypertension" without first excluding pseudoresistance (poor measurement technique, white coat effect, medication nonadherence, suboptimal drug choices) and secondary causes 1
• Do not overlook medication adherence—poor compliance is the most common cause of uncontrolled hypertension; use once-daily dosing and single-pill combinations 1, 6