From the Guidelines
For a 73-year-old male on metoprolol with uncontrolled hypertension (BP 150s/90s), I recommend optimizing the current regimen by adding a second antihypertensive medication from a different class, such as a thiazide diuretic, calcium channel blocker, or ACE inhibitor, as the current evidence suggests that combination therapy is often necessary to achieve target blood pressure levels 1. The patient's current blood pressure is above the recommended target, and adding a new medication can help to reduce the risk of cardiovascular complications.
- Good options for the second medication include:
- A thiazide diuretic like hydrochlorothiazide 12.5-25mg daily
- A calcium channel blocker like amlodipine 5-10mg daily
- An ACE inhibitor like lisinopril 10-20mg daily The patient should monitor blood pressure at home twice daily for two weeks after any medication change and follow up with his physician to evaluate the response.
- Lifestyle modifications are also important, including:
- Reducing sodium intake to less than 2300mg daily
- Regular physical activity (30 minutes most days)
- Weight management
- Limiting alcohol
- Following a DASH diet rich in fruits, vegetables, and low-fat dairy According to the 2020 international society of hypertension global hypertension practice guidelines, if the patient's blood pressure remains uncontrolled, consideration should be given to screening for secondary causes of hypertension and optimizing the current treatment regimen, including the use of a diuretic-based treatment and potentially adding a low dose of spironolactone as a fourth-line agent 1.
- The guidelines also recommend that resistant hypertension should be managed in specialist centers with sufficient expertise and resources necessary to diagnose and treat this condition. It's worth noting that the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD, recommend a blood pressure target of <130/80 mmHg for patients with diabetes, but for older adults, a target of <130-139/80 mmHg is recommended 1. However, the most recent and highest quality study, the 2020 international society of hypertension global hypertension practice guidelines, should be prioritized in this case 1.
From the FDA Drug Label
The geriatric population may show slightly higher plasma concentrations of metoprolol as a combined result of a decreased metabolism of the drug in elderly population and a decreased hepatic blood flow. However, this increase is not clinically significant or therapeutically relevant In controlled clinical studies, metoprolol has been shown to be an effective antihypertensive agent when used alone or as concomitant therapy with thiazide-type diuretics, at oral dosages of 100 to 450 mg daily
The patient's blood pressure is still elevated despite being on metoprolol for hypertension. The dosage of metoprolol may need to be adjusted. The drug label suggests that metoprolol can be effective at oral dosages of 100 to 450 mg daily. Considering the patient is 73 years old, no reduction in dosage is usually needed in patients with chronic renal failure, but hepatic impairment may impact the pharmacokinetics of metoprolol. The patient's dosage should be evaluated and potentially adjusted to achieve optimal blood pressure control 2.
- Key considerations:
- Patient's age and potential decreased metabolism of the drug
- Current dosage and potential need for adjustment
- Presence of any hepatic impairment or renal failure
- Next steps:
- Evaluate the patient's current dosage and adjust as needed
- Monitor the patient's blood pressure and adjust the dosage accordingly
- Consider potential interactions with other medications or underlying health conditions 2
From the Research
Patient's Condition
The patient is a 73-year-old male with hypertension, currently being treated with metoprolol. Despite the treatment, his blood pressure remains elevated, ranging from 150's over 90's.
Treatment Options
- According to 3, metoprolol is effective in treating mild to moderate hypertension, and its beta 1-selectivity makes it a suitable option for certain patients, such as asthmatics and diabetics.
- The study 4 describes the various pharmacological classes of antihypertensive drugs, including beta-blockers like metoprolol, and their mechanisms of action and side effects.
- Combination therapy with other antihypertensive drugs, such as diuretics, angiotensin-converting enzyme inhibitors, and calcium channel blockers, may be considered to improve blood pressure control, as suggested by 5 and 6.
Potential Next Steps
- Dose titration of metoprolol within the therapeutic range may be necessary to achieve optimal treatment of hypertension, as mentioned in 3.
- Adding a diuretic to the treatment regimen may improve the overall response rate in hypertension, as stated in 3.
- Considering alternative or additional treatment options, such as angiotensin II receptor blockers, calcium channel blockers, or renin inhibitors, may be necessary to achieve better blood pressure control, as discussed in 4, 5, and 6.