From the Guidelines
If lisinopril-HCTZ 20-25 mg is not effectively controlling blood pressure, the next step typically involves increasing to lisinopril-HCTZ 40-25 mg once daily, which is the maximum recommended dose for this combination. This approach is supported by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. The guideline recommends more rapid titration of antihypertensive medications in patients with BP >20/10 mm Hg above their target, and initiation of antihypertensive therapy with 2 agents is recommended in these patients.
Before increasing the dose, it's essential to confirm the patient is taking the medication consistently, following sodium restriction guidelines, and implementing lifestyle modifications like regular exercise and weight management. The dose adjustment is based on the principle that ACE inhibitors like lisinopril have a dose-dependent effect on blood pressure, while hydrochlorothiazide's effect plateaus at 25 mg.
Some key considerations when adjusting the dose include:
- Monitoring blood pressure regularly after any dose change
- Checking kidney function and electrolytes within 1-2 weeks of adjustment, particularly in elderly patients or those with kidney disease
- Being aware of the increased risk of side effects like dizziness, hypotension, and electrolyte disturbances with higher doses
- Considering the addition of a third antihypertensive medication from a different class if the adjusted dose does not achieve target blood pressure, such as amlodipine (5-10 mg daily), a calcium channel blocker.
From the FDA Drug Label
If blood pressure is not controlled with lisinopril tablets alone, a low dose of a diuretic may be added (e.g., hydrochlorothiazide, 12. 5 mg). The recommended starting dose in adult patients with hypertension taking diuretics is 5 mg once per day. Dosage should be adjusted according to blood pressure response up to a maximum of 0.61 mg per kg (up to 40 mg) once daily.
The recommended dose change when lisinopril-hctz 20-25 mg is not effective enough is to adjust the dosage according to blood pressure response. The maximum dose is 40 mg once daily. However, the label does not provide specific guidance on dose escalation when the initial combination is not effective. 2
From the Research
Recommended Dose Change for Lisinopril-HCTZ
When lisinopril-HCTZ 20-25 mg is not effective enough, the following options can be considered:
- Increasing the dose of lisinopril-HCTZ, as high doses (32.5 to 35mg) of lisinopril have been shown to be more effective than low doses (2.5 to 5mg) in reducing the risk of major clinical events in patients with heart failure 3
- Switching to a twice-daily dosing regimen, as twice-daily administration of lisinopril has been associated with greater blood pressure reductions compared to once-daily administration 4
- Adding other antihypertensive medications to the treatment regimen, as concomitant therapy with lisinopril and hydrochlorothiazide has been shown to provide blood pressure reduction beyond that of either monocomponent 5
Potential Benefits and Risks
The potential benefits of increasing the dose or switching to a twice-daily dosing regimen include:
- Greater reduction in blood pressure and risk of major clinical events
- Improved symptomatic benefits in patients with congestive heart failure However, the potential risks include:
- Increased incidence of adverse events, such as hypotension and worsening renal function 3
- Increased frequency of treatment discontinuations due to adverse events 6