How to optimize antihypertensive therapy in a 43-year-old female with Hypertension (elevated Blood Pressure), mild Left Ventricular Hypertrophy (LVH), and Diabetes Mellitus (DM), currently on Lisinopril (Angiotensin-Converting Enzyme Inhibitor) 20 mg and Hydrochlorothiazide (HCTZ) (Thiazide Diuretic) 25 mg, after discontinuation of Amlodipine (Calcium Channel Blocker) due to peripheral edema?

From the Guidelines

To optimize this patient's antihypertensive therapy, I recommend adding spironolactone 25 mg daily to her current regimen of lisinopril 20 mg and hydrochlorothiazide 25 mg, as this approach is supported by the most recent guidelines for managing hypertension, particularly in patients with diabetes and resistant hypertension 1. The patient's current blood pressure of 170/100 mmHg, despite being on two medications, indicates resistant hypertension, and the addition of a third agent with a different mechanism of action is necessary.

Rationale for Spironolactone

• Spironolactone is a potassium-sparing aldosterone antagonist that is particularly effective for resistant hypertension, as noted in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
• It provides a complementary mechanism of action to the patient's current ACE inhibitor (lisinopril) and diuretic (hydrochlorothiazide), which is in line with the recommendation to combine drugs from different classes for additive or synergistic effects 1.
• The use of spironolactone may also help in reversing left ventricular hypertrophy (LVH), a condition the patient has, while avoiding the peripheral edema she experienced with amlodipine.

Monitoring and Adjustments

• Blood pressure should be monitored weekly after initiating spironolactone, with a target of <130/80 mmHg given her diabetes, as recommended by the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1.
• Potassium levels should be checked within 1-2 weeks of starting spironolactone due to the risk of hyperkalemia when combined with an ACE inhibitor.
• If spironolactone is contraindicated or not tolerated, consider adding a beta-blocker such as metoprolol succinate 25-50 mg daily, which would be beneficial given her left ventricular hypertrophy.

Comprehensive Treatment Plan

• Medication adherence, sodium restriction, and regular physical activity should also be emphasized as part of her comprehensive treatment plan.
• The patient should be encouraged to self-monitor her blood pressure, especially since she has diabetes, as suggested by the guidelines 1.
• Lifestyle changes, including diet and exercise, should be guided by the recommendations for patients with diabetes and hypertension, aiming for optimal blood pressure control and reduction of micro- and macrovascular complications 1.

From the FDA Drug Label

The antihypertensive effect of lisinopril was seen with 5 mg of lisinopril in some patients However, in both studies blood pressure reduction occurred sooner and was greater in patients treated with 10 mg, 20 mg or 80 mg of lisinopril than patients treated with 5 mg of lisinopril. Lisinopril demonstrated superior reductions of systolic and diastolic compared to hydrochlorothiazide in a population that was 75% Caucasian The LIFE study was a multinational, double-blind study comparing losartan and atenolol in 9193 hypertensive patients with ECG-documented left ventricular hypertrophy. Treatment with losartan resulted in a 13% reduction (p=0. 021) in risk of the primary endpoint compared to the atenolol group

To optimize her antihypertensive therapy, consider the following options:

• Increase the dose of lisinopril: Since the patient is already on 20 mg of lisinopril, increasing the dose to 40 mg or 80 mg may provide additional blood pressure reduction, as seen in the clinical studies 2.
• Add or substitute with losartan: Losartan has been shown to be effective in reducing blood pressure in patients with left ventricular hypertrophy, and may be a suitable alternative or addition to the patient's current therapy 3.
• Monitor and adjust: Continue to monitor the patient's blood pressure and adjust the treatment regimen as needed to achieve optimal blood pressure control.

From the Research

Optimizing Antihypertensive Therapy

To optimize antihypertensive therapy for the 43-year-old female patient with elevated blood pressure (170/100 mmHg), mild left ventricular hypertrophy (LVH), diabetes mellitus (DM), and currently on lisinopril 20 mg and hydrochlorothiazide (HCTZ) 25 mg, several considerations must be taken into account:

• The patient's blood pressure is not adequately controlled on her current medication regimen.
• She has a history of peripheral edema due to amlodipine, which limits the use of certain calcium channel blockers.
• The presence of diabetes mellitus and LVH suggests the need for tight blood pressure control to reduce the risk of cardiovascular complications.

Current Medication Regimen

The patient is currently on lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, and HCTZ, a diuretic. According to the study 4, ACE inhibitors like lisinopril are effective in controlling blood pressure and reducing the risk of cardiovascular events. However, the patient's blood pressure remains elevated, suggesting the need for additional or alternative therapy.

Alternative Therapies

Considering the patient's history of peripheral edema with amlodipine, alternative calcium channel blockers may be considered. However, the study 5 suggests that lisinopril may be better tolerated than nifedipine, another calcium channel blocker. Beta-blockers may also be considered, especially in patients with diabetes and LVH, as they can help reduce blood pressure and cardiovascular risk 6.

Combination Therapy

The study 7 highlights the importance of combination therapy in achieving blood pressure targets, especially in patients with concomitant diseases like diabetes and coronary heart disease. The patient may benefit from the addition of another antihypertensive agent, such as a beta-blocker or an angiotensin receptor blocker (ARB), to her current regimen.

Key Considerations

When optimizing the patient's antihypertensive therapy, the following key considerations should be taken into account:

• The need for tight blood pressure control to reduce cardiovascular risk in patients with diabetes and LVH.
• The potential for adverse effects, such as peripheral edema, with certain medications.
• The importance of combination therapy in achieving blood pressure targets.
• The selection of medications that are effective and well-tolerated in patients with concomitant diseases.