What is the optimal plan of care to manage uncontrolled stage 2 hypertension in a 69-year-old female patient with an allergy to Belsomra (Suvorexant), taking Cardizem (Diltiazem) 420mg extended release once daily, with a blood pressure of 143/86?

From the Guidelines

To better manage this patient's stage 2 hypertension, I recommend adding a thiazide diuretic such as hydrochlorothiazide 12.5mg daily to her current regimen of Cardizem 420mg extended release. The combination of a calcium channel blocker (Cardizem) with a thiazide diuretic provides complementary mechanisms of action for blood pressure control, as supported by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. If this combination doesn't achieve the target blood pressure within 4 weeks, consider increasing hydrochlorothiazide to 25mg daily or adding an ACE inhibitor like lisinopril 10mg daily. The patient should also be counseled on lifestyle modifications including:

• Sodium restriction
• Regular physical activity
• Weight management
• Limiting alcohol consumption It's essential to monitor her electrolytes, particularly potassium and magnesium, after starting the diuretic, as recommended in the guideline 1. Additionally, her Ativan use for insomnia should be reassessed, as benzodiazepines are generally not recommended for long-term use in elderly patients and may be contributing to her hypertension management difficulties, as noted in the guideline 1. Consider a non-benzodiazepine alternative for her insomnia that doesn't conflict with her belsorma allergy. Regular follow-up appointments every 2-4 weeks are recommended until her blood pressure is consistently below 130/80 mmHg, in line with the guideline's recommendations for follow-up and treatment of stage 2 hypertension 1.

From the Research

Current Medications and Allergies

• The patient is currently taking Cardizem 420mg extended release once daily for hypertension management.
• The patient has an allergy to Belsomra.
• Other medications include Polyethylene Glycol, Ferrous Sulfate, Dilantin, Pravastatin Sodium, Dexilant, Alendronate Sodium, and Ativan.

Blood Pressure Management

• The patient's current blood pressure is 143/86, which is not adequately controlled.
• According to 2, first-line therapy for hypertension includes lifestyle modification and pharmacologic therapy with a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker.
• The patient is currently taking a calcium channel blocker (Cardizem), but may benefit from additional or alternative therapy to achieve better blood pressure control.

Alternative Therapies

• Angiotensin-converting enzyme inhibitors, such as lisinopril 3, have been shown to be effective in lowering blood pressure and reducing the risk of cardiovascular disease.
• However, 4 suggests that angiotensin receptor blockers may be a better option due to their similar efficacy and lower risk of adverse events.
• Thiazide diuretics, such as hydrochlorothiazide, may also be considered as an alternative or additional therapy 2, 5.

Considerations for Treatment

• The patient's age (69 years) and comorbidities (anemia, seizures, cholesterol management, GERD, osteoporosis, and anxiety/insomnia) should be taken into account when selecting a treatment plan.
• The patient's current medications and potential interactions should also be considered when adding or modifying therapies.
• Lifestyle modifications, such as weight loss, dietary changes, and increased physical activity, should also be encouraged to help manage blood pressure 2, 5.