What medication can help improve hypertension in an older adult with chronic neck or back pain and hypertension?

Medication Selection for Hypertension in Older Adults with Chronic Pain

For an older adult with chronic neck or back pain and hypertension, avoid NSAIDs and initiate a thiazide-like diuretic (chlorthalidone or indapamide), ACE inhibitor, or dihydropyridine calcium channel blocker as first-line therapy, targeting a systolic blood pressure below 150 mmHg. 1, 2

Critical Consideration: NSAIDs and Hypertension

NSAIDs commonly used for chronic pain directly interfere with antihypertensive therapy and should be discontinued or minimized. 1 This creates a therapeutic challenge in patients with chronic musculoskeletal pain, but blood pressure control must take priority given the mortality implications.

Blood Pressure Target

• Target systolic BP <150 mmHg for adults aged 60 years or older, which reduces all-cause mortality by 1.64%, stroke by 1.13%, and cardiac events by 1.25% 1, 2
• For patients aged 60-79 years, a target of <140 mmHg is acceptable if well-tolerated 1
• For those ≥80 years, 140-145 mmHg is acceptable if tolerated 1

First-Line Medication Algorithm

For Non-Black Patients:

1. Start with low-dose ACE inhibitor (e.g., lisinopril 5-10 mg daily) 2, 3
2. If inadequate response after 2-4 weeks, increase to full dose 2
3. If BP remains uncontrolled, add thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide) 1, 2
4. If still uncontrolled, add dihydropyridine calcium channel blocker (e.g., amlodipine 5-10 mg daily) 2, 4

For Black Patients:

1. Start with ARB plus dihydropyridine calcium channel blocker OR calcium channel blocker plus thiazide-like diuretic 2
2. Black patients have smaller responses to ACE inhibitor monotherapy 1, 3
3. Combination therapy eliminates racial differences in blood pressure response 1

Specific Medication Classes

Five major drug classes have proven cardiovascular benefit in older adults: 1

• Thiazide-like diuretics (chlorthalidone, indapamide preferred over hydrochlorothiazide) 1
• ACE inhibitors 1, 3
• Angiotensin receptor blockers 1
• Calcium channel blockers 1, 4
• Beta-blockers (less preferred in elderly due to unfavorable side effect profile) 2

Dosing Principles for Older Adults

• Start at the lowest dose and titrate gradually due to age-related changes in drug metabolism and excretion 1
• Approximately two-thirds of older adults require ≥2 medications to achieve target BP 1
• Single-pill combination therapy improves adherence and should be considered once multiple agents are needed 1, 2
• Monitor for orthostatic hypotension when initiating or adjusting therapy 2

Essential Lifestyle Modifications

Implement these interventions immediately alongside pharmacotherapy: 1, 2

• DASH diet (rich in fruits, vegetables, low-fat dairy; low in saturated fat) 1
• Sodium restriction to <2.3 g/day - older adults show larger BP reductions with sodium restriction than younger adults 1
• Weight reduction if overweight - declines in BP with weight loss are larger in older than younger adults 1
• Regular physical activity: 30-60 minutes of moderate-intensity aerobic exercise 4-7 days per week 5, 6
• Alcohol limitation: ≤2 drinks/day for men, ≤1 for women 1
• Smoking cessation 1

Monitoring Strategy

• Follow-up within 2-4 weeks after medication initiation or dose changes 2
• Achieve target BP within 3 months 2
• Use home BP monitoring (target <135/85 mmHg) to confirm office readings and assess treatment efficacy 1, 2
• Monitor serum potassium when using ACE inhibitors (approximately 15% of patients have increases >0.5 mEq/L) 3

Common Pitfalls to Avoid

Avoid excessive diastolic BP lowering (<70-75 mmHg) in older patients with coronary disease, as this may reduce coronary blood flow and increase CHD events 1

Do not continue ineffective monotherapy - if BP remains uncontrolled after adequate trial of first agent at full dose, add a second agent rather than switching 1, 2

Screen for medication non-adherence - up to 25% of patients don't fill initial prescriptions, and only 1 in 5 achieves adherence levels seen in clinical trials 1

Assess for frailty and multiple comorbidities, which may warrant more conservative targets and slower titration 2, 7