Antihypertensive Management in Addison's Disease After Amlodipine Intolerance
An angiotensin II receptor blocker (ARB) such as losartan or an ACE inhibitor should be the next agent considered for this patient with Addison's disease and hypertension who cannot tolerate amlodipine. 1
First-Line Alternative: RAAS Blockade
Why ARBs or ACE Inhibitors Are Optimal
ARBs (such as losartan) or ACE inhibitors are the treatment of choice in patients with Addison's disease and hypertension when renin levels are in the upper normal range or elevated, which is common in this population 1
The renin-angiotensin system is critically involved in maintaining blood pressure in Addison's disease, making RAAS blockade particularly physiologically appropriate 2
Losartan 50 mg once daily is a reasonable starting dose, with potential titration to 100 mg daily if needed for blood pressure control 3
These agents can be safely used without adjusting the fludrocortisone dose when there are no signs of mineralocorticoid excess 1
Critical Pre-Treatment Steps
Before initiating any antihypertensive beyond fludrocortisone adjustment:
Optimize glucocorticoid replacement first and consider dose reduction if excessive, as over-replacement can contribute to hypertension 1
Review and potentially reduce fludrocortisone dose if there are clinical or biochemical signs of mineralocorticoid excess (hypokalemia, suppressed renin, edema) 1
If renin is appropriately elevated or upper-normal range without signs of mineralocorticoid excess, proceed with RAAS blockade while maintaining current fludrocortisone dose 1
Second-Line Option: Dihydropyridine Calcium Channel Blockers
Alternative CCB Selection
If an alternative calcium channel blocker is needed (rather than amlodipine), other dihydropyridine CCBs such as felodipine can be considered as second-line agents in Addison's disease 1
Dihydropyridine CCBs are clinically useful as add-on therapy but should not be first-line in this population 1
Avoid non-dihydropyridine CCBs (diltiazem, verapamil) as they have negative inotropic effects and should be avoided in patients with potential cardiac complications 4
Agents to Avoid in Addison's Disease
Contraindicated or Problematic Medications
Diuretics should be avoided in hypertensive patients with Addison's disease unless heart failure is present, as these patients already have impaired sodium retention 1
Aldosterone antagonists (spironolactone, eplerenone) are contraindicated in Addison's disease due to the underlying mineralocorticoid deficiency 1
Alpha-blockers like doxazosin should only be used if other agents are inadequate at maximum tolerated doses 4
Monitoring Considerations
Key Parameters to Track
Monitor renin levels to guide fludrocortisone dosing adjustments, though these become less helpful if heart failure develops 1
Check electrolytes regularly, particularly potassium and sodium, when initiating RAAS blockade 3
Assess for orthostatic hypotension, which may indicate over-treatment or inadequate mineralocorticoid replacement 1
Target blood pressure should be <130/80 mm Hg in most patients with hypertension 4