What is the next step in managing a 76-year-old male with persistent hypertension despite being on amlodipine (10mg), valsartan (Valtaran) (320mg), furosemide (Lasix) (40mg), and metoprolol (25mg twice daily)?

From the Guidelines

This patient's blood pressure remains uncontrolled despite being on multiple antihypertensive medications, and I recommend simplifying the regimen with once daily dosing and single pill combinations, and considering the addition of spironolactone 25mg daily as the next step in management. The patient is currently on amlodipine, Vallarta, lasix, and metoprolol, which is a complex regimen that may be contributing to non-adherence. According to the 2020 international society of hypertension global hypertension practice guidelines 1, simplifying the regimen with once daily dosing and single pill combinations is recommended. Additionally, spironolactone is an aldosterone antagonist that can be particularly effective in resistant hypertension by addressing a mechanism not targeted by the patient's current regimen. Before starting spironolactone, it is essential to check the patient's potassium and renal function, as hyperkalemia is a potential side effect 1.

Some key points to consider in the management of this patient's hypertension include:

• Ensuring medication adherence is assessed, as non-adherence is a common cause of apparent resistant hypertension
• Reinforcing lifestyle modifications, including sodium restriction to less than 2g daily, regular physical activity, weight loss if applicable, limiting alcohol consumption, and following the DASH diet
• Considering secondary causes of hypertension such as obstructive sleep apnea, primary aldosteronism, renal artery stenosis, or pheochromocytoma, especially in patients with resistant hypertension despite multiple medications
• Monitoring the patient's blood pressure regularly and adjusting the treatment regimen as needed to achieve a target blood pressure of <130/80 mm Hg 1.

It is also important to note that the patient's age and potential frailty should be taken into account when making treatment decisions, and that monotherapy may be considered in low-risk grade hypertension and in patients aged >80 years or frail 1. However, in this case, the patient's blood pressure is not well-controlled, and additional treatment is necessary to reduce the risk of cardiovascular complications.

From the FDA Drug Label

The usual initial dose of Furosemide tablets for hypertension is 80 mg, usually divided into 40 mg twice a day. The dose may be raised by 20 or 40 mg and given not sooner than 6 to 8 hours after the previous dose until the desired diuretic effect has been obtained. The patient is currently taking Lasix (furosemide) 40mg, which is lower than the recommended initial dose for hypertension.

• The dose of Lasix (furosemide) could be increased to achieve better blood pressure control.
• However, the patient is also taking Vallarta (valsartan) 320mg, Amlodipine 10mg, and Metoprolol 25mg bid, and the interaction between these medications and the increased dose of Lasix (furosemide) should be carefully monitored.
• It is also important to note that the patient's blood pressure is still not well-controlled, and other factors such as the patient's kidney function, electrolyte levels, and overall health status should be taken into consideration when adjusting the medication regimen 2 3.

From the Research

Patient's Current Medication Regimen

The patient is currently taking amlodipine 10mg, valsartan 320mg, lasix 40mg, and metoprolol 25mg bid. Despite this regimen, the patient's blood pressure remains elevated at 168/95.

Efficacy of Amlodipine/Valsartan Combination

• Studies have shown that the combination of amlodipine and valsartan is effective in reducing blood pressure in patients with hypertension 4, 5.
• The combination therapy has been shown to be more effective than monotherapy with either amlodipine or valsartan in reducing blood pressure in patients with mild to moderate hypertension 4.
• The BP-lowering effect of amlodipine plus valsartan was not significantly different from that of other combinations of antihypertensive drugs, including amlodipine plus atenolol, lisinopril plus hydrochlorothiazide, and irbesartan plus hydrochlorothiazide 4.

Comparison of Different Antihypertensive Drug Combinations

• A study compared the efficacy of different combinations of antihypertensive therapy on blood pressure and arterial stiffness, and found that lisinopril, losartan, or valsartan alone or in combination with hydrochlorothiazide, with or without amlodipine, were equally effective in reducing blood pressure and improving arterial stiffness in patients with essential hypertension 6.
• Another study compared the fixed-dose combination of amlodipine/valsartan with valsartan monotherapy, and found that the combination therapy was superior to monotherapy in reducing blood pressure 7.

Potential Next Steps

• Consider adjusting the patient's medication regimen to optimize blood pressure control, potentially by increasing the dose of amlodipine or valsartan, or adding another antihypertensive agent 4, 5, 7.
• Monitor the patient's blood pressure and adjust the treatment plan as needed to achieve optimal blood pressure control 6, 7.