What's an alternative to lisinopril (angiotensin-converting enzyme inhibitor) + hydrochlorothiazide (HCTZ, diuretic) for an older adult patient experiencing dizziness?

Alternative to Lisinopril-Hydrochlorothiazide for Dizziness in Older Adults

Switch to amlodipine (calcium channel blocker) 5-10 mg daily as monotherapy or combined with a reduced dose of hydrochlorothiazide (12.5 mg), as this addresses the dizziness likely caused by excessive blood pressure lowering from the ACE inhibitor component while maintaining effective hypertension control. 1

Understanding the Cause of Dizziness

The dizziness is most likely due to:

• Orthostatic hypotension from the ACE inhibitor (lisinopril), which is a well-documented adverse effect causing dizziness, hypotension, and syncope 1
• Excessive blood pressure lowering below the patient's tolerance threshold, particularly common in older adults 1
• The hydrochlorothiazide component can contribute through volume depletion and electrolyte disturbances 1

Primary Recommendation: Switch to Calcium Channel Blocker-Based Therapy

Replace the lisinopril-hydrochlorothiazide combination with amlodipine 5-10 mg daily, either as monotherapy or combined with hydrochlorothiazide 12.5 mg. 2, 3

Why Amlodipine is the Best Alternative:

• Lower risk of orthostatic hypotension and dizziness compared to ACE inhibitors, though dizziness can still occur with calcium channel blockers at a lower rate 1
• Equally effective as first-line therapy for hypertension in older adults per ACC/AHA guidelines 3
• Well-tolerated in elderly patients with isolated systolic hypertension 4
• Can be combined with the existing hydrochlorothiazide if monotherapy is insufficient, as the calcium channel blocker plus thiazide combination is endorsed by multiple international guidelines 2

Specific Dosing Strategy

Start with amlodipine 5 mg daily and titrate to 10 mg if needed before adding back hydrochlorothiazide. 2

• If blood pressure remains uncontrolled on amlodipine 10 mg alone, add hydrochlorothiazide 12.5 mg (not 25 mg) to minimize orthostatic effects 2, 1
• This stepwise approach allows you to identify the minimum effective dose that controls blood pressure without causing dizziness 2

Alternative Option: ARB-Based Therapy

If the patient has a compelling indication for renin-angiotensin system blockade (heart failure, diabetic nephropathy), switch to valsartan 80-160 mg plus hydrochlorothiazide 12.5 mg. 3, 5

Why ARBs May Be Better Tolerated:

• Lower incidence of dizziness compared to ACE inhibitors (though still possible) 1
• No cough, which is a common ACE inhibitor side effect 1
• Similar efficacy to ACE inhibitors for cardiovascular protection 3
• The valsartan-hydrochlorothiazide combination showed better tolerability than amlodipine in elderly patients with isolated systolic hypertension, with significantly fewer adverse events (20.2% vs 31.9%) 4

Blood Pressure Target Adjustment

Reassess the blood pressure target to ensure it's not overly aggressive for this older adult patient. 1

• For adults ≥60 years, target systolic blood pressure <150 mm Hg (strong recommendation) 1
• Only consider targets <140 mm Hg if the patient has history of stroke/TIA or high cardiovascular risk, and can tolerate it without symptoms 1
• Treating to lower targets (<140 mm Hg) increases risk of syncope, hypotension, and dizziness without substantial additional mortality benefit 1

Critical Monitoring Steps

Before making any medication changes:

• Measure standing blood pressure to confirm orthostatic hypotension (drop ≥20 mm Hg systolic or ≥10 mm Hg diastolic within 3 minutes of standing) 1, 3
• Check serum electrolytes and renal function to rule out hyponatremia or hypokalemia from hydrochlorothiazide as contributing factors 1, 6
• Verify medication adherence and timing - taking medications at bedtime rather than morning may reduce daytime dizziness 1

After switching medications:

• Reassess blood pressure within 2-4 weeks to evaluate response 2
• Recheck electrolytes and creatinine if continuing hydrochlorothiazide 2
• Monitor for peripheral edema if using amlodipine, which occurs in up to 27% of elderly patients on higher doses 4

Medications to Avoid

Do not use beta-blockers as an alternative unless the patient has coronary artery disease, heart failure, or prior myocardial infarction, as they offer limited efficacy and increased side effects (including dizziness and fatigue) in older adults 2, 3

Avoid alpha-blockers and central alpha-agonists (clonidine, moxonidine), which cause significant orthostatic hypotension and dizziness in elderly patients 2, 1

Do not combine ACE inhibitor with ARB, as this increases risk of hyperkalemia, syncope, and acute kidney injury without additional benefit 7

Common Pitfalls to Avoid

• Don't assume all dizziness is medication-related - rule out other causes (dehydration, anemia, cardiac arrhythmias, vestibular disorders) before changing therapy 1
• Don't discontinue all antihypertensives abruptly - this can cause rebound hypertension 1
• Don't ignore the possibility that the patient needs a less aggressive blood pressure target rather than different medications 1
• Don't restart the same dose of hydrochlorothiazide if adding it back - use the lower 12.5 mg dose to minimize orthostatic effects 2, 1