What is the best approach to manage a 47-year-old male's uncontrolled hypertension, given his complex medical history including chronic pain, steatosis of the liver, DVT, pulmonary embolism, and cervical lymphadenopathy, while also addressing his opioid use disorder and goal to taper off Suboxone (buprenorphine/naloxone)?

Management of Uncontrolled Hypertension in a 47-Year-Old Male with Complex Medical History

This patient requires immediate initiation of combination antihypertensive therapy with an ACE inhibitor (or ARB) plus a dihydropyridine calcium channel blocker, given his severely elevated blood pressure of 179/108 mmHg and history of thromboembolic disease, while simultaneously coordinating care for his opioid use disorder and investigating his unexplained lymphadenopathy and prior thrombotic events. 1

Immediate Blood Pressure Management

Urgency of Treatment

• Blood pressure of 179/108 mmHg requires prompt pharmacological intervention within days to weeks, not months, particularly given his history of DVT, pulmonary embolism, and documented uncontrolled hypertension dating back years. 1
• This does not constitute a hypertensive emergency (no acute end-organ damage), so oral therapy is appropriate rather than IV medications. 1
• The patient's longstanding non-adherence and lack of current antihypertensive medication despite known hypertension represents a critical treatment gap. 1

Recommended Initial Regimen

• Start combination therapy immediately with two agents: a RAS blocker (ACE inhibitor such as lisinopril 10-20 mg daily OR an ARB) combined with a dihydropyridine calcium channel blocker (such as amlodipine 5-10 mg daily). 1
• Combination therapy is superior to monotherapy for achieving blood pressure control and is recommended as initial treatment for confirmed hypertension ≥140/90 mmHg. 1
• Use fixed-dose single-pill combinations when available to improve adherence, which is particularly important given this patient's history of medication non-adherence. 1

Blood Pressure Target

• Target systolic blood pressure of 120-129 mmHg if well tolerated, as this reduces cardiovascular risk in most adults. 1
• If this target cannot be achieved due to tolerability issues, apply the "as low as reasonably achievable" (ALARA) principle. 1

Medication Timing and Adherence

• Consider administering at least one antihypertensive medication at bedtime, as this has been associated with reduced cardiovascular events and mortality in patients with type 2 diabetes and hypertension. 1
• Take medications at the most convenient time to establish a habitual pattern and improve adherence. 1
• Address barriers to adherence including cost and side effects at each visit. 1

Special Considerations for This Patient

History of Thromboembolic Disease

• The patient's history of bilateral lower extremity DVT and pulmonary embolism is concerning, particularly given he reports discontinuing Eliquis (apixaban) on advice from a provider. 2, 3
• Pulmonary embolism can cause right ventricular dysfunction and is a significant cause of cardiovascular mortality. 2
• Urgent hematology consultation is essential to determine if anticoagulation should be resumed, especially given the unexplained nature of his clotting history and ongoing lymphadenopathy. 3
• The documented referrals to hematology and cancer centers from prior years require immediate follow-up to ensure continuity of this critical evaluation. 3

Hepatic Steatosis

• Fatty liver disease is documented and requires consideration when selecting medications. 1
• ACE inhibitors and ARBs are generally safe in hepatic steatosis and may have metabolic benefits. 1
• Obtain baseline liver function tests and basic metabolic panel before initiating therapy and monitor periodically. 1
• The pruritus on his arms could represent early liver disease progression and warrants investigation. 1

Opioid Use Disorder and Chronic Pain Management

Buprenorphine/Naloxone (Suboxone) Considerations

• The patient is prescribed buprenorphine/naloxone 8mg/2mg three times daily but reports taking only one strip daily, indicating either inadequate dosing for his needs or medication diversion concerns. 4
• Buprenorphine has minimal direct cardiac effects but can prolong QTc interval, particularly at higher doses. 5
• Obtain baseline ECG to assess QTc interval before continuing buprenorphine therapy, and repeat after any dose adjustments. 5
• Buprenorphine-naloxone can improve pain scores in patients with chronic pain and is well-tolerated. 4
• The dose of buprenorphine/naloxone is not strongly correlated with pain intensity improvement; other factors including psychiatric comorbidities play a larger role. 6

Coordination with Prescribing Provider

• Immediate communication with the prescribing provider in the other location is essential to clarify the intended dosing regimen and address the discrepancy between prescribed and reported use. 4
• If the patient genuinely requires only one strip daily, the prescription should be adjusted to prevent accumulation and potential diversion. 4
• The patient's stated goal of tapering off buprenorphine should be addressed collaboratively with the prescribing provider, but this should not be rushed given his history of transition from prescribed to illicit fentanyl. 4

Blood Pressure Medications and Opioid Interactions

• Most antihypertensive medications have minimal interactions with buprenorphine. 5
• Avoid combining multiple CNS depressants, though standard antihypertensive doses are generally safe. 5
• Monitor for orthostatic hypotension, as both opioids and some antihypertensives (particularly alpha-blockers) can cause this. 5

Unexplained Lymphadenopathy and Systemic Symptoms

Diagnostic Urgency

• The patient has a 3+ year history of cervical and inguinal lymphadenopathy with extensive but inconclusive workups including negative infectious disease testing and autoimmune panels. 1
• Current worsening right groin pain radiating to abdomen requires urgent evaluation. 1
• Prior imaging showed prominent mesenteric lymph nodes, possible terminal ileitis, and hilar lymphadenopathy. 1

Required Immediate Actions

• Obtain all records from recent ER visits (two visits in past four months for chest pain with extensive workups). 1
• Verify status of hematology and oncology referrals from prior years and expedite appointments if not completed. 1
• Order updated imaging as clinically indicated based on current symptoms and prior findings. 1
• Consider repeat CT chest/abdomen/pelvis to assess progression of lymphadenopathy and evaluate current groin/abdominal pain. 1

Secondary Hypertension Screening

• At age 47 with longstanding uncontrolled hypertension and unexplained systemic findings, secondary causes must be considered. 7
• Comprehensive screening is particularly important in younger adults with hypertension. 7
• Obtain basic screening tests: serum creatinine with eGFR, electrolytes (particularly potassium to screen for primary aldosteronism), urinalysis, and lipid panel. 1, 7
• Given the history of bilateral DVT/PE and lymphadenopathy, consider whether an underlying hypercoagulable state or systemic inflammatory condition could be contributing to hypertension. 7
• Obstructive sleep apnea screening is essential given his chronic pain, obesity risk factors, and resistant hypertension pattern. 1, 7

Lifestyle Modifications (Essential Concurrent Interventions)

Dietary Interventions

• Restrict sodium intake to <2,300 mg/day (or <1,500 mg/day for more aggressive control). 1
• Increase consumption of fruits and vegetables (8-10 servings/day) and low-fat dairy products (2-3 servings/day). 1
• Restrict free sugar consumption to maximum 10% of energy intake and avoid sugar-sweetened beverages. 1

Alcohol and Tobacco

• Assess current alcohol consumption and limit to ≤2 drinks/day for men (preferably avoid entirely for best outcomes). 1
• If smoking, initiate smoking cessation with supportive care and referral to cessation programs. 1

Physical Activity and Weight Management

• Encourage minimum 30 minutes of aerobic exercise on most days of the week, which can reduce systolic BP by 4-7 mmHg and diastolic by 3-5 mmHg. 1
• Weight loss of 10 kg is associated with average 6 mmHg systolic and 4.6 mmHg diastolic reduction. 1
• Given his history of thoracic radiculopathy from intervertebral disc disorder and chronic pain, tailor exercise recommendations to avoid exacerbating pain. 1

Monitoring Plan

Short-Term Follow-Up

• Recheck blood pressure within 1-2 weeks after initiating therapy to assess response and tolerability. 7
• Continue frequent visits (every 2-4 weeks) until blood pressure target is achieved. 7
• Home blood pressure monitoring is strongly recommended for medication titration and ongoing assessment. 1, 7

Medication Titration

• If BP not controlled with two-drug combination, escalate to three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic (preferably as single-pill combination). 1
• Never combine two RAS blockers (ACE inhibitor + ARB). 1
• If BP remains uncontrolled despite optimal doses of three agents including a diuretic, evaluate for secondary hypertension and medication adherence. 1

Long-Term Management

• Maintain BP-lowering treatment lifelong, even beyond age 85 if well tolerated. 1
• Regular monitoring of renal function, electrolytes, and liver function given his hepatic steatosis. 1
• Annual lipid panels and diabetes screening given cardiovascular risk factors. 1

Critical Pitfalls to Avoid

Medication-Related

• Do not delay treatment waiting for lifestyle modifications alone given the severity of hypertension (179/108 mmHg). 1
• Do not start with monotherapy in this patient with stage 2 hypertension; combination therapy is indicated. 1
• Do not overlook the anticoagulation question—his history of bilateral DVT/PE requires urgent hematology input before assuming discontinuation was appropriate. 3
• Do not ignore the buprenorphine dosing discrepancy—this requires immediate clarification with the prescribing provider. 4

Diagnostic Pitfalls

• Do not attribute all symptoms to known conditions without investigating the unexplained lymphadenopathy and systemic symptoms that have persisted for 3+ years. 1
• Do not assume primary hypertension without appropriate screening for secondary causes in a 47-year-old with longstanding uncontrolled hypertension. 7
• Do not overlook cardiac evaluation given his history of PE, which can cause chronic right ventricular dysfunction. 2

Coordination of Care

• Do not manage this patient in isolation—he requires coordinated care involving hematology, addiction medicine, and potentially oncology. 1, 4
• Obtain all outside records immediately to avoid duplicating workups and to ensure continuity of the lymphadenopathy evaluation. 1
• Verify completion of prior referrals to hematology and cancer centers that were documented in previous notes. 1