From the Guidelines
For a 38-year-old female with new onset hypertension who is taking multiple psychiatric medications (Cymbalta, lithium, Seroquel, sertraline) and an oral contraceptive pill, I recommend initiating an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) as first-line antihypertensive therapy, as they have demonstrated the most effective reduction of blood pressure and cardiovascular disease events 1. The choice between an ACE inhibitor and an ARB should be based on the patient's individual characteristics and potential interactions with her current medications.
- ACE inhibitors, such as lisinopril, are a good option, but it's essential to monitor her lithium levels periodically, as ACE inhibitors can increase lithium concentration 1.
- ARBs, such as losartan, are a suitable alternative, especially if the patient is planning pregnancy or has a history of angioedema. It's crucial to avoid diuretics, as they may interact with lithium and increase toxicity risk.
- Calcium channel blockers are another option if ACE inhibitors or ARBs are contraindicated, but they may interact with some of her psychiatric medications, and their use should be carefully considered. The patient should also be counseled on lifestyle modifications, including sodium restriction, regular exercise, and weight management, to complement pharmacological treatment.
- The goal is to achieve a blood pressure target below 130/80 mmHg, and the patient's blood pressure should be monitored regularly after starting treatment 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Considerations for Hypertensive Medication
When considering the best antihypertensive medication to initiate for a 38-year-old female with new onset hypertension who is currently on multiple medications (Cymbalta, lithium, Kataya pain, Seroquel, sertraline, and an OCP), several factors must be taken into account:
- The patient's current medication regimen and potential interactions with antihypertensive medications
- The need to simplify the medication regimen to improve compliance, as suggested by 2
- The efficacy and tolerability of different antihypertensive medication combinations
Antihypertensive Medication Combinations
Studies have shown that combination therapy with an angiotensin II receptor blocker (ARB) and a diuretic or calcium channel blocker can be effective in reducing blood pressure:
- The combination of losartan and hydrochlorothiazide (HCTZ) has been shown to be effective in reducing blood pressure and is considered a cost-effective option with fewer adverse effects on uric acid and other metabolic parameters, as noted in 3
- The combination of an ARB and a calcium channel blocker, such as amlodipine, has also been shown to be effective, but may have different effects on renal parameters, as seen in 4
Renal Effects of Antihypertensive Medications
The renal effects of losartan and amlodipine have been compared in hypertensive patients with non-diabetic nephropathy:
- Losartan has been shown to decrease albumin excretion and filtration fraction, while amlodipine had no significant effect on these parameters, as reported in 4
- The combination of an ARB and a diuretic, such as HCTZ, may increase serum uric acid in patients with low baseline levels, as noted in 5
Simplification of Medication Regimens
Simplifying complex medication regimens can improve compliance and reduce the risk of medication errors:
- Strategies for simplification include consolidating dosing times, standardizing routes of administration, and using combination products, as described in 2
- The use of single-pill, fixed-dose combinations of antihypertensive medications, such as ARB and diuretic combinations, can aid in simplifying medication regimens and improving compliance, as suggested by 6