This patient also has hypertension, taking 10mg Lisinopril (Angiotensin-Converting Enzyme Inhibitor) and 5mg Amlodipine (Calcium Channel Blocker), with persistent hypertension, which medication should be increased first?

From the Guidelines

I would recommend increasing the lisinopril (an ACE inhibitor) from 10 mg to 20 mg first, rather than increasing the amlodipine (a calcium channel blocker). When managing uncontrolled hypertension on dual therapy, it's generally preferable to optimize the ACE inhibitor dose before maximizing the calcium channel blocker, as suggested by the 2020 international society of hypertension global hypertension practice guidelines 1. Lisinopril is typically effective up to 40 mg daily, while the patient is only on 10 mg currently. This approach may provide better blood pressure control through enhanced renin-angiotensin system blockade. Additionally, maximizing the ACE inhibitor offers cardioprotective and renoprotective benefits beyond blood pressure reduction.

Some key points to consider when managing hypertension include:

• Optimizing the current treatment regimen, including health behavior change and diuretic-based treatment, as recommended by the 2020 guidelines 1
• Considering the addition of a low-dose spironolactone as a 4th line agent in patients with resistant hypertension, as suggested by the 2020 guidelines 1 and the 2017 acc/aha/aapa/abc/acpm/ags/apha/ash/aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1
• Monitoring for side effects after each dose adjustment, particularly checking for cough with increased lisinopril and peripheral edema with amlodipine
• Ensuring the patient is following lifestyle modifications, including sodium restriction, regular exercise, and weight management, as these can significantly impact blood pressure control

If blood pressure remains elevated after increasing lisinopril to 20 mg and allowing 2-4 weeks for full effect, then consider increasing amlodipine from 5 mg to 10 mg. It's also important to note that the patient's current regimen does not include a diuretic, which is often recommended as part of a comprehensive treatment plan for hypertension, as suggested by the 2020 guidelines 1.

From the FDA Drug Label

The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose. The recommended starting dose for lisinopril tablets, when used with diuretics and (usually) digitalis as adjunctive therapy for systolic heart failure, is 5 mg once daily. The usual initial antihypertensive oral dose of Amlodipine besylate tablets is 5 mg once daily, and the maximum dose is 10 mg once daily.

The patient is currently taking 10 mg of lisinopril and 5 mg of amlodipine. To manage the patient's high blood pressure, it is recommended to increase the dose of lisinopril first, as the current dose is at the lower end of the recommended dosage range of 20 mg to 40 mg per day. Increasing the dose of lisinopril to 20 mg per day may help to better control the patient's blood pressure. The dose of amlodipine can be increased to 10 mg per day if necessary, but this should be done after assessing the patient's response to the increased dose of lisinopril. 2 3

From the Research

Patient's Current Medication and Condition

• The patient is currently taking 10mg of lisinopril and 5mg of amlodipine for hypertension.
• Despite the current medication, the patient's blood pressure remains high.

Considerations for Increasing Medication

• According to the study 4, lisinopril is an effective antihypertensive medication that can be taken once daily, with a range of blood pressure reductions of 11-15% in systolic and 13-17% in diastolic.
• The study 5 also supports the use of lisinopril as an effective treatment for essential hypertension, with many patients achieving adequate blood pressure reduction with lisinopril alone.
• However, the study 6 suggests that in patients whose blood pressures are not controlled by the combination of amlodipine and lisinopril, the addition of a diuretic (such as hydrochlorothiazide) may be more effective than adding a beta-blocker.

Decision on Which Medication to Increase First

• Based on the studies 4 and 5, increasing the dose of lisinopril may be a viable option to further reduce blood pressure.
• However, considering the patient is already taking 10mg of lisinopril, it may be more effective to add a diuretic (as suggested by study 6) or increase the dose of amlodipine, as the combination of amlodipine and lisinopril has a synergistic effect in patients with more severe hypertension 7, 8.
• The study 8 also shows that combined therapy with lisinopril and amlodipine can lead to significant reductions in blood pressure and improvement in cardiovascular and renal outcomes.

Potential Next Steps

• Consider increasing the dose of amlodipine to 10mg, as the patient is currently taking 5mg, to take advantage of the synergistic effect of the combination therapy.
• Alternatively, consider adding a diuretic, such as hydrochlorothiazide, to the patient's current medication regimen, as suggested by study 6.
• Monitor the patient's blood pressure closely after any changes to their medication regimen to assess the effectiveness of the new treatment plan.