What are the guideline interventions for a 62-year-old female patient with stage 1-2 hypertension, currently managed with metoprolol (beta blocker) 25 milligrams once daily?

From the Guidelines

For a 62-year-old female with stage 1-2 hypertension despite metoprolol 25 mg daily, the recommended intervention is to optimize her antihypertensive therapy by either increasing the metoprolol dose or adding a second agent from a different class, such as a renin-angiotensin system inhibitor or a diuretic, as suggested by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. The patient's current monotherapy with metoprolol 25 mg once daily may not be sufficient for adequate blood pressure control, particularly considering her stage 1-2 hypertension.

• The guideline recommends lifestyle changes plus drug therapy for those with existing cardiovascular disease (CVD) or increased CVD risk, and the patient's blood pressure thresholds indicate the need for intensified treatment.
• Intensive blood pressure-lowering therapies should be directed toward patients with the highest atherosclerotic cardiovascular disease (ASCVD) risk, and the patient's age and hypertension stage suggest a higher risk.
• The American College of Cardiology/American Heart Association Pooled Cohort Equations can be used to assess the patient's ASCVD risk and guide treatment decisions.
• The addition of a second agent from a different class, such as a thiazide diuretic or a calcium channel blocker, can provide better blood pressure control with fewer side effects than high-dose monotherapy, as different medications target different physiological pathways of blood pressure regulation, as noted in the guideline 1.
• Lifestyle modifications, including sodium restriction, regular physical activity, weight management, limiting alcohol consumption, and following a DASH diet, should also be emphasized to support blood pressure control and overall cardiovascular health.

From the FDA Drug Label

DOSAGE & ADMINISTRATION In patients with severe intolerance, discontinue metoprolol tartrate (see WARNINGS) Geriatric Patients (>65 years) In general, use a low initial starting dose in elderly patients given their greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

The patient is currently on monotherapy metoprolol 25 mg once daily. Given that the patient's blood pressure is stage 1-2 hypertensive, the current dosage may not be sufficient.

• The drug label does not provide specific guidance on managing hypertension in patients with stage 1-2 hypertension.
• However, it does mention that geriatric patients should be started on a low initial dose and titrated according to clinical response.
• Since the patient is already on a low dose, consideration could be given to increasing the dose or adding another agent to achieve better blood pressure control, but this is not explicitly stated in the label.
• The label also mentions that patients with severe intolerance should discontinue metoprolol tartrate, but this does not apply to the current situation. 2

From the Research

Guideline Interventions for Hypertension Management

The patient is currently managing hypertension with monotherapy metoprolol 25 mg once daily. Given the patient's stage 1-2 hypertensive blood pressure, the following guideline interventions can be considered:

• Combination therapy: According to 3, more than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents. The four main classes of medications used in combination therapy are thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs).
• Adding a second agent: Studies 4 and 5 suggest that adding an ACE inhibitor, such as lisinopril, to a beta-blocker, such as metoprolol, can be an effective treatment option. Alternatively, adding a diuretic, such as hydrochlorothiazide, can also be considered 4, 6.
• Monitoring and adjusting treatment: Regular monitoring of blood pressure and adjusting treatment as needed is crucial to achieve adequate blood pressure control 3, 6.
• Consideration of patient characteristics: The choice of treatment should take into account the patient's individual characteristics, such as age, comorbidities, and potential side effects 3, 6.

Potential Treatment Options

Based on the available evidence, potential treatment options for the patient could include:

• Increasing the dose of metoprolol or switching to a sustained-release formulation 7
• Adding an ACE inhibitor, such as lisinopril, to the current metoprolol therapy 4, 5
• Adding a diuretic, such as hydrochlorothiazide, to the current metoprolol therapy 4, 6
• Considering alternative combination therapies, such as a calcium channel blocker or an ARB, if the patient is not responding to the current treatment or is experiencing side effects 3