What is the best course of action for an elderly male patient with elevated blood pressure (hypertension), presenting with lower back and right hip pain, who is requesting a renewal of his ibuprofen (nonsteroidal anti-inflammatory drug) and is currently out of his metoprolol (beta blocker)?

Management of Elderly Male with Elevated BP, Musculoskeletal Pain, and Lapsed Antihypertensive Therapy

Do not renew ibuprofen for this patient; instead, restart metoprolol immediately and prescribe acetaminophen for pain management, as NSAIDs like ibuprofen significantly interfere with antihypertensive efficacy and can elevate blood pressure by 6-7 mm Hg in patients on beta-blockers. 1, 2

Immediate Priority: Address the Hypertension Crisis

Restart Metoprolol Without Delay

• Metoprolol must be restarted immediately because abrupt discontinuation in patients with hypertension can cause severe exacerbation of blood pressure, and the FDA explicitly warns against interruption of chronically administered beta-blocker therapy without physician supervision 3
• The elevated BP reading today is likely multifactorial: both from medication non-adherence and potential ibuprofen use 1, 2
• Restart at the patient's previous maintenance dose if known, or initiate at 50 mg twice daily with gradual titration if this is a new diagnosis 3
• For elderly patients, the FDA recommends using low initial starting doses with cautious gradual titration given their greater frequency of decreased hepatic, renal, or cardiac function 3

Blood Pressure Target and Monitoring

• Target BP should be <130/80 mm Hg for this patient, as the ACC/AHA guidelines recommend this target for adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher 4
• Critical: Measure blood pressure in both sitting and standing positions to assess for orthostatic hypotension, which is essential in elderly patients 5
• Follow-up within 1-2 weeks after restarting metoprolol to assess BP control and adverse effects 6

Pain Management: Why Ibuprofen Must Be Avoided

The NSAID-Antihypertensive Interaction

• Ibuprofen significantly reduces the efficacy of beta-blockers like metoprolol through inhibition of vasodilatory prostaglandins that increase renal blood flow and promote sodium/water excretion 1
• In a randomized controlled trial, ibuprofen 400 mg three times daily increased mean arterial pressure by 6.6 mm Hg (95% CI: 1.25-11.95) in patients on antihypertensive therapy after just 3 weeks 2
• The interaction typically manifests after more than 5 days of concurrent use, and while blood pressure changes are often small, some patients experience substantial elevations in both systolic and diastolic pressure 1
• This interaction has been estimated to potentially cause over 30,000 deaths from myocardial infarction in the United States if left unaddressed 1

Recommended Alternative: Acetaminophen

• Acetaminophen is the preferred analgesic for persistent pain in older persons according to the American Geriatrics Society guidelines 4
• Acetaminophen does not interfere with antihypertensive medications and showed no significant blood pressure elevation in head-to-head comparison with ibuprofen 2
• Dosing: Acetaminophen 1000 mg orally every 8 hours (maximum 3000 mg/day in elderly patients to minimize hepatotoxicity risk) 4
• The oral route is preferable because of its convenience and relatively steady blood concentrations 4

Evaluation of Musculoskeletal Pain

Essential Clinical Assessment

• Determine pain characteristics: onset (started after walking a few weeks ago), location (right hip and lower back), severity, aggravating/relieving factors 4
• Assess functional impairment: Can the patient perform activities of daily living? Is quality of life affected? 4
• Physical examination should focus on: range of motion of the hip, tenderness to palpation, gait assessment, neurological examination of lower extremities to rule out radiculopathy 4
• Red flags requiring urgent evaluation: fever, unexplained weight loss, history of cancer, severe night pain, bowel/bladder dysfunction, progressive neurological deficits 4

Pain Management Goals

• Comfort goals should be mutually established to manage pain to a level that allows the patient to engage in activities and achieve acceptable quality of life, rather than expecting complete absence of pain 4
• Positive outcomes are maximized when clinicians regularly monitor patients for adverse effects of analgesics 4

Additional Antihypertensive Considerations

If BP Remains Uncontrolled on Metoprolol Alone

• Add a thiazide-like diuretic (chlorthalidone preferred) or dihydropyridine calcium channel blocker as second-line therapy 5
• Chlorthalidone is superior to hydrochlorothiazide for cardiovascular outcomes and is the preferred thiazide-like diuretic according to the American Heart Association 5
• Effective two-drug combinations include: beta-blocker + thiazide diuretic, or beta-blocker + calcium channel blocker 4, 5

Monitoring for Adverse Effects

• Monitor heart rate and rhythm, as bradycardia (including sinus pause, heart block, and cardiac arrest) can occur with metoprolol 3
• If severe bradycardia develops, reduce or stop metoprolol 3
• Monitor for signs of heart failure, as beta-blockers can cause depression of myocardial contractility 3
• Check electrolytes if adding thiazide diuretics, monitoring particularly for hypokalemia 5

Critical Pitfalls to Avoid

• Never abruptly discontinue metoprolol, especially in patients who may have unrecognized coronary artery disease, as this can precipitate severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 3
• Do not prescribe NSAIDs to patients on antihypertensive therapy without considering the significant drug interaction and BP elevation risk 1, 2
• Do not ignore standing blood pressure measurements in elderly patients, as orthostatic hypotension increases fall risk 5
• Avoid rapid dose escalation in elderly patients, as this increases risk of adverse effects including orthostatic hypotension and falls 5