What antihypertensive medication is recommended for a patient with ulcerative colitis, hypertension, and diabetes, currently on 45mg of Rinvoq (upadacitinib) qd (once daily) and 35mg of Prednisone (prednisone) qd, while tapering the prednisone?

Antihypertensive Selection for Diabetic Patient with Ulcerative Colitis on Rinvoq and Prednisone

An ACE inhibitor or angiotensin receptor blocker (ARB) should be initiated as first-line therapy for this patient with diabetes and hypertension, as these agents provide both blood pressure control and renal protection in diabetic patients. 1

Primary Recommendation: ACE Inhibitor or ARB

• ACE inhibitors or ARBs are the recommended first-line antihypertensive agents for patients with diabetes and hypertension, regardless of baseline urinary albumin levels, as they reduce cardiovascular events and provide nephroprotection. 1

• If the patient has albuminuria (urinary albumin-to-creatinine ratio ≥30 mg/g), an ACE inhibitor or ARB is strongly recommended and should be titrated to the maximum tolerated dose indicated for blood pressure treatment. 1

• If one class is not tolerated due to side effects (such as cough with ACE inhibitors or angioedema), the other should be substituted immediately. 1

Critical Monitoring Considerations

• Serum creatinine, estimated glomerular filtration rate (eGFR), and serum potassium levels must be monitored at baseline and at least annually when using ACE inhibitors or ARBs, particularly given the concurrent use of prednisone which can affect electrolyte balance. 1

• Weekly home blood pressure monitoring is recommended for the first month after initiating Rinvoq, then every 6 months thereafter, as upadacitinib can elevate blood pressure in patients with pre-existing hypertension. 2

Additional Antihypertensive Agents if Monotherapy Insufficient

• If blood pressure targets (<140/80 mmHg for diabetics) are not achieved with ACE inhibitor or ARB monotherapy, add either a thiazide-like diuretic (chlorthalidone or indapamide preferred) or a dihydropyridine calcium channel blocker as second-line therapy. 1

• Multiple-drug therapy is generally required to achieve blood pressure targets in diabetic patients, with most requiring at least two agents at adequate doses. 1

• For patients with blood pressure ≥160/100 mmHg, initiate two antihypertensive medications simultaneously or use a single-pill combination to achieve more rapid blood pressure control. 1

Prednisone-Specific Considerations

• Prednisone at 35 mg daily significantly worsens hypertension through sodium retention and volume expansion, making aggressive blood pressure management essential during the corticosteroid taper. 2

• The British Society of Gastroenterology explicitly states that prednisone should only be used for short-term induction (optimal dose 40 mg/day) and must not be continued for maintenance in ulcerative colitis, with gradual tapering over 6-8 weeks once clinical improvement occurs. 1, 2

• Blood pressure typically improves as prednisone is tapered, but antihypertensive therapy should not be delayed while waiting for steroid reduction. 2

Blood Pressure Targets

• Target systolic blood pressure <140 mmHg and diastolic blood pressure <80 mmHg for this diabetic patient. 1

• Lower targets (systolic <130 mmHg) may be appropriate if achievable without undue treatment burden, particularly in younger patients. 1

Contraindicated Combinations

• Never combine an ACE inhibitor with an ARB, as this increases the risk of hyperkalemia, syncope, and acute kidney injury without providing additional cardiovascular benefit. 1

• Do not combine ACE inhibitors or ARBs with direct renin inhibitors for the same reasons. 1

Practical Implementation Algorithm

1. Check baseline urinary albumin-to-creatinine ratio, serum creatinine, eGFR, and potassium before initiating therapy. 1

2. Start an ACE inhibitor (e.g., lisinopril 10 mg daily) or ARB (e.g., losartan 50 mg daily) as first-line therapy. 1

3. Recheck blood pressure in 2-4 weeks; if not at target, titrate to maximum tolerated dose. 1

4. If blood pressure remains elevated after 4 weeks on maximum ACE inhibitor/ARB dose, add a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) or dihydropyridine calcium channel blocker (amlodipine 5-10 mg daily). 1

5. Monitor serum creatinine, eGFR, and potassium 1-2 weeks after initiating therapy and then at least annually. 1

6. Implement weekly home blood pressure monitoring for the first month, then as clinically indicated, given concurrent Rinvoq therapy. 2

Common Pitfalls to Avoid

• Failing to initiate antihypertensive therapy promptly while waiting for prednisone taper—blood pressure control should begin immediately. 1

• Using inadequate doses of ACE inhibitors or ARBs—titrate to maximum tolerated doses for optimal cardiovascular and renal protection. 1

• Not monitoring renal function and potassium after initiating ACE inhibitors/ARBs, particularly in patients on multiple medications affecting electrolytes. 1

• Combining ACE inhibitors with ARBs, which increases adverse events without additional benefit. 1