What is the management plan for a 57-year-old male, 5 days post-discharge, with uncontrolled Hypertension (HTN), currently taking Lisinopril (Angiotensin-Converting Enzyme Inhibitor) 30mg and Amlodipine (Calcium Channel Blocker) 10mg daily, after being hospitalized for Hypertensive crisis, pneumonia, hyponatremia, and anxiety, with a history of excessive alcohol consumption?

From the Guidelines

The patient's antihypertensive medication regimen should be intensified immediately by adding a thiazide diuretic, such as hydrochlorothiazide 12.5 mg daily, to his current regimen of lisinopril 30 mg and amlodipine 10 mg daily, as his blood pressure remains dangerously elevated at 180/98 despite current therapy. This recommendation is based on the most recent guidelines for the management of elevated blood pressure and hypertension, which suggest that combination therapy with drugs from different classes can have additive or synergistic effects and lead to greater blood pressure reduction than increasing the dose of one drug 1. The combination of an ACE inhibitor (lisinopril), calcium channel blocker (amlodipine), and thiazide diuretic (hydrochlorothiazide) provides synergistic blood pressure lowering effects through different mechanisms - vasodilation, reduced peripheral resistance, and decreased fluid volume, respectively.

Some key points to consider in the management of this patient's hypertension include:

• The importance of complete alcohol cessation, as alcohol was likely contributing to his hypertension crisis and medication resistance 1
• The need to screen for alcohol withdrawal symptoms, which can emerge up to 7-10 days after cessation in heavy drinkers and can worsen hypertension
• The potential for his recent hyponatremia to improve with continued alcohol abstinence, but the need to recheck electrolytes at follow-up
• The recommendation to monitor his blood pressure twice daily and follow up within one week to reassess control
• The consideration of referral to a hypertension specialist if blood pressure remains uncontrolled after this three-drug regimen, as outlined in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

It is also important to note that the 2018 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 provides a comprehensive overview of the management of hypertension, including the use of different classes of antihypertensive medications, such as beta blockers, alpha-1 blockers, and direct vasodilators 1. However, the most recent guidelines from 2024 should take precedence in guiding the management of this patient's hypertension 1.

From the FDA Drug Label

The recommended initial dose is 10 mg once a day. Dosage should be adjusted according to blood pressure response. The usual dosage range is 20 mg to 40 mg per day administered in a single daily dose. 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 lisinopril 30 mg and amlodipine 10 mg daily, with a blood pressure of 180/98.

• The dosage of lisinopril is within the recommended range of 20-40 mg per day.
• The dosage of amlodipine is at the maximum recommended dose of 10 mg once daily. Given the patient's current blood pressure, it may be necessary to adjust the dosage of one or both medications to achieve better blood pressure control 2, 3, 3.

From the Research

Patient's Current Condition

• The patient is a 57-year-old male who was hospitalized for HTN crisis, pneumonia, hyponatremia, and anxiety.
• He was drinking 12 beers/day but has stopped drinking since discharge.
• The patient is currently taking lisinopril 30 and amlodipine 10 daily.
• His current blood pressure is 180/98, which is 5 days after discharge.

Blood Pressure Management

• According to the study 4, the patient's current blood pressure is considered a hypertensive urgency, which requires blood pressure to be lowered within 24 to 48 hours to avoid hypertensive target organ damage.
• The study 5 suggests that lifestyle therapy is recommended for patients with stage 1 hypertension, but the patient's current blood pressure is above the stage 1 hypertension range.
• The study 6 found that different combinations of antihypertensive therapy, including lisinopril and amlodipine, are effective in reducing blood pressure and improving arterial stiffness in patients with essential hypertension.

Hyponatremia and Medication

• The study 7 reports a case of severe hyponatremia associated with lisinopril, which suggests that the patient's hyponatremia may be related to his medication.
• However, the study 7 also notes that the patient's hyponatremia improved after discontinuing lisinopril and restarting it later, which suggests that the relationship between lisinopril and hyponatremia is complex.

Future Management

• The study 8 suggests that improving patients' adherence to medication and blood pressure control is crucial for effective hypertension management.
• The patient's current medication regimen and blood pressure monitoring should be reviewed and adjusted as necessary to achieve better blood pressure control.
• The study 8 also recommends the use of out-of-office blood pressure monitoring techniques, such as telemonitoring and mobile health technologies, to improve blood pressure control and patient engagement.