What is the best management approach for a female adult with hyperpigmented macules on her trunk, on prednisone, with a history of hypertension (on captopril), hyperlipidemia (high LDL), and hyperglycemia (elevated FBS), now presenting with potential hypotension?

Immediate Management: Discontinue Prednisone and Address Hypotension

The prednisone must be discontinued immediately as it is likely causing or exacerbating both the hyperglycemia and hypertension, while the current blood pressure of 80/90 mmHg represents significant hypotension requiring urgent evaluation and management. 1, 2

Critical Assessment of Current Situation

Blood Pressure Crisis

• A blood pressure of 80/90 mmHg is hypotensive and potentially dangerous, particularly in a patient previously hypertensive on captopril 1
• Assess for orthostatic hypotension by measuring blood pressure in both sitting and standing positions 1, 3
• Immediately evaluate for volume depletion, excessive captopril dosing, or acute illness that may be precipitating hypotension 2
• Consider holding or reducing captopril dose until blood pressure stabilizes above 90 mmHg systolic 2

Prednisone-Induced Complications

• Systemic corticosteroids like prednisone are well-documented causes of elevated blood pressure and hyperglycemia 1
• The hyperpigmented macules on the trunk do not justify continued prednisone use given the severe metabolic consequences 4, 5
• Prednisone should be tapered (not abruptly stopped if used >2-3 weeks) to avoid adrenal insufficiency, which could also contribute to hypotension 1

Immediate Actions (Next 24-48 Hours)

Hypotension Management

• Hold captopril temporarily if systolic BP remains <90 mmHg 2
• Assess for signs of shock: altered mental status, decreased urine output, cool extremities 2
• Rule out volume depletion: check for dehydration, recent vomiting/diarrhea, or excessive diuretic use 2
• If volume depleted, initiate IV normal saline resuscitation 2

Medication Review

• Discontinue or rapidly taper prednisone under medical supervision 1
• Review for other medications that may cause hypotension or interact with captopril 2
• Check serum creatinine, electrolytes (especially potassium), and renal function 1, 2

Short-Term Management (1-2 Weeks)

Blood Pressure Stabilization

• Once BP stabilizes above 100/60 mmHg, restart captopril at a lower dose (6.25-12.5 mg three times daily) and titrate carefully 2
• Target blood pressure should be <130/80 mmHg once stable, given her cardiovascular risk factors 1
• Implement home blood pressure monitoring to track patterns and avoid both hypo- and hypertensive episodes 1, 3

Hyperglycemia Management

• Expect fasting blood glucose to improve significantly after prednisone discontinuation 1
• Recheck fasting glucose 1-2 weeks after stopping prednisone 1
• If hyperglycemia persists, initiate lifestyle modifications: reduce saturated fat to <7% of calories, increase fiber intake to 10-25 g/day, and encourage modest weight loss 1

Long-Term Management (Ongoing)

Hypertension Control

• Captopril is appropriate as first-line therapy given her metabolic profile, as ACE inhibitors do not adversely affect lipids or glucose 6
• If blood pressure remains uncontrolled on captopril alone, add a thiazide diuretic (hydrochlorothiazide 25 mg daily) 2
• Titrate captopril up to 50 mg three times daily if needed, with maximum dose of 150 mg three times daily 2
• Monitor for orthostatic hypotension, especially given her age and previous hypotensive episode 1

Dyslipidemia Management

• Initiate statin therapy for elevated LDL cholesterol, as she is high-risk with multiple cardiovascular risk factors 1
• Target LDL-C <100 mg/dL through lifestyle modifications and pharmacotherapy 1
• Dietary modifications: limit saturated fat to <7% of energy, cholesterol to <200 mg/day, and eliminate trans fats 1
• Add plant stanols/sterols (2 g/day) and increase soluble fiber (10-25 g/day) to enhance LDL lowering 1

Lifestyle Interventions

• Sodium restriction to <2,400 mg/day (ideally <2,300 mg/day) for both hypertension and cardiovascular risk reduction 1, 7
• Encourage weight loss if overweight, as this benefits both blood pressure and lipid profile 1
• Regular physical activity adapted to her capabilities 7
• Limit alcohol to ≤1 drink daily for women 7

Hyperpigmented Macules

• The trunk macules likely represent postinflammatory hyperpigmentation, melasma, or benign lentigines and do not require systemic corticosteroids 4, 5
• If treatment is desired, consider topical agents (hydroquinone, tretinoin), chemical peels, or laser therapy 4, 5
• Perform skin examination to exclude melanoma or systemic disease manifestations 4, 5

Monitoring Schedule

Initial Phase (First Month)

• Check blood pressure 2-4 weeks after any medication adjustment 1, 2
• Monitor serum creatinine, electrolytes, and potassium 2-4 weeks after initiating or adjusting captopril 1, 7
• Recheck fasting glucose and lipid panel 4 weeks after prednisone discontinuation 1

Long-Term Follow-Up

• Blood pressure monitoring at every visit, with home monitoring between visits 1, 7
• Annual assessment of renal function, electrolytes, fasting glucose, and lipid profile 1, 7
• Lifelong blood pressure treatment is recommended if well tolerated 7

Critical Pitfalls to Avoid

• Never restart prednisone for benign skin lesions when safer alternatives exist 1, 4, 5
• Do not ignore hypotension in a previously hypertensive patient—this represents a significant change requiring investigation 1, 2
• Avoid potassium supplements, potassium-sparing diuretics, or salt substitutes containing potassium while on captopril without close monitoring 2
• Do not use NSAIDs, as they can worsen hypertension control and interact with captopril 1, 2, 8
• Ensure adequate follow-up within 2-4 weeks after medication changes to assess response and adjust therapy 1