What is the next treatment plan for an elderly patient with uncontrolled hypertension (blood pressure 170/110) on losartan (angiotensin II receptor antagonist) 50mg and amlodipine (calcium channel blocker) 2.5mg, who has shown no improvement since last week?

Treatment Plan for Uncontrolled Hypertension in Elderly Patient

Immediate Next Step

Uptitrate amlodipine from 2.5 mg to 5 mg daily and increase losartan from 50 mg to 100 mg daily. 1, 2, 3

Rationale for Dose Optimization

Your patient is on subtherapeutic doses of both medications. The current regimen represents only 25% of maximum amlodipine dose and 50% of target losartan dose, leaving substantial room for intensification before adding additional agents. 1, 2

Amlodipine Dose Escalation

• Amlodipine 2.5 mg is a starting dose; the therapeutic range extends to 10 mg daily for elderly patients. 1
• Increasing to 5 mg provides additional systolic BP reduction with excellent tolerability in elderly populations. 1, 4
• Dihydropyridine calcium channel blockers like amlodipine do not cause bradycardia and are particularly well-suited for elderly patients. 1
• Start with gradual titration (2.5 mg → 5 mg) to minimize vasodilatory side effects such as peripheral edema. 1

Losartan Dose Escalation

• The target dose for losartan is 100 mg daily for hypertension, with evidence supporting up to 150 mg daily for additional cardiovascular benefit. 2, 3
• Higher doses of ARBs provide greater BP reduction and cardiovascular protection than lower doses—a 10% relative risk reduction in cardiovascular events was demonstrated with losartan 150 mg versus 50 mg daily. 2, 3
• Losartan 50 mg represents only 50% of the standard target dose, making uptitration the logical next step before adding a third agent. 2

Stepwise Treatment Algorithm

1. Week 0 (Now): Increase amlodipine to 5 mg daily AND losartan to 100 mg daily. 1, 2, 3

2. Week 2-4: Recheck BP, serum creatinine, and potassium. 3

   • Monitor for orthostatic hypotension by checking BP in both sitting and standing positions. 5, 1
   • If BP remains ≥140/90 mmHg, proceed to step 3.

3. Week 4-8: If BP still uncontrolled, increase amlodipine to 10 mg daily. 1

   • Alternatively, add a thiazide-like diuretic (chlorthalidone 12.5 mg or indapamide 1.25 mg daily) if amlodipine causes intolerable peripheral edema. 1

4. Week 8-12: If triple therapy needed, add chlorthalidone 12.5 mg daily (NOT 25 mg due to hypokalemia risk in elderly). 1

Blood Pressure Target

• Primary goal: <140/90 mmHg for elderly patients if well-tolerated. 5, 1
• If the patient is robust and tolerates therapy well, consider targeting <130/80 mmHg for additional cardiovascular risk reduction. 1
• Achieve target BP within 3 months of treatment intensification. 1, 3

Critical Monitoring Parameters

• Recheck BP within 2-4 weeks after any medication adjustment. 1, 3
• Monitor serum potassium and creatinine within 1-2 weeks after increasing losartan dose, especially given the elderly population and risk of hyperkalemia. 2, 3
• Assess for orthostatic hypotension at every visit—elderly patients have increased risk of postural BP drops. 5, 1
• Watch for peripheral edema if amlodipine is increased to 10 mg (occurs in ~27% at higher doses). 6

Common Pitfalls to Avoid

• Do not add a third medication class before maximizing doses of existing agents. Combination therapy at subtherapeutic doses is less effective than optimizing current medications. 1
• Avoid chlorthalidone doses >12.5 mg in elderly patients. Doses of 25-50 mg increase hypokalemia risk 3-fold and eliminate cardiovascular protection. 1
• Never combine losartan with an ACE inhibitor. This combination increases hyperkalemia and renal dysfunction risk without additional benefit. 2
• Do not undertitrate based on age alone. Base treatment intensity on functional status and tolerability, not chronological age. 1
• Avoid rapid titration in elderly patients. Initial doses and subsequent increases should be gradual to prevent adverse effects. 5, 3

Why Not Add a Diuretic Immediately?

While adding a thiazide-like diuretic is a valid option, optimizing existing medications first is preferred because:

• Both current medications are at subtherapeutic doses with proven dose-response relationships. 1, 2
• Polypharmacy increases non-adherence and adverse effects in elderly patients. 1
• Diuretics carry electrolyte disturbance risks that require additional monitoring. 1

However, if the patient develops intolerable peripheral edema from higher-dose amlodipine, substituting or adding chlorthalidone 12.5 mg daily becomes the preferred alternative. 1