From the Guidelines
The plan of care for this 75-year-old male with uncontrolled hypertension should focus on optimizing his current antihypertensive regimen, with a goal to target systolic BP to 130 mmHg and diastolic BP to <80 mmHg, as recommended by the 2020 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1.
Current Medications and Potential Issues
The patient is currently taking Olmesartan Medoxomil/hydrochlorothiazide 40mg-12.5mg once daily for hypertension, which is a good combination but may need adjustment. Considering his current blood pressure of 130/79 in the clinic, which is actually at goal for his age and comorbidities, but his report of stage 1-2 hypertension at home suggests white coat normotension or possible medication timing issues.
Recommendations
- Increase his Olmesartan/HCTZ to the maximum dose of 40mg-25mg daily, as he's currently on 40mg-12.5mg, to optimize his current treatment regimen, including health behavior change and diuretic-based treatment, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1.
- Consider adding a fourth agent, such as spironolactone, as the 4th line agent, if his serum potassium is <4.5 mmol/L and his eGFR is >45 ml/min/1.73m2, to achieve BP targets, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1.
- The patient should monitor his blood pressure at home twice daily (morning and evening) and keep a log to bring to follow-up appointments.
- Lifestyle modifications are essential, including sodium restriction to less than 2300mg daily, regular physical activity (30 minutes of moderate exercise most days), weight management if needed, and limiting alcohol consumption.
- The patient should also be evaluated for medication adherence and proper blood pressure measurement technique.
- A 24-hour ambulatory blood pressure monitor would be valuable to assess his true blood pressure pattern.
- Finally, review potential drug interactions, particularly between his antihypertensives and erectile dysfunction medications (tadalafil and sildenafil), which can cause additive hypotensive effects.
From the FDA Drug Label
Olmesartan medoxomil tablets are indicated for the treatment of hypertension in adults and children six years of age and older, to lower blood pressure. Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. Many patients will require more than one drug to achieve blood pressure goals For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) The usual recommended starting dose of olmesartan medoxomil tablets is 20 mg once daily when used as monotherapy in patients who are not volume-contracted. For patients requiring further reduction in blood pressure after 2 weeks of therapy, the dose of olmesartan medoxomil tablets may be increased to 40 mg
The patient is already taking Olmesartan Medoxomil/hydrochlorothiazide 40mg-12.5mg once daily for hypertension. Considering the patient's current medication regimen and blood pressure readings, the plan of care to improve his blood pressure could include:
- Monitoring and adjusting the current medication regimen as needed, with close attention to the patient's blood pressure readings and overall health status.
- Lifestyle modifications, such as:
- Exercise: regular physical activity to help lower blood pressure
- Diet: a balanced diet that is low in sodium and rich in fruits, vegetables, and whole grains
- Smoking cessation: if the patient is a smoker
- Regular follow-up appointments with the healthcare provider to monitor the patient's blood pressure and adjust the treatment plan as needed 2. It is also important to consider the patient's comorbidities, such as diabetes, and ensure that they are being managed effectively 2.
From the Research
Patient Profile
- 75-year-old male patient with a chief complaint of inability to control blood pressure at home
- Past medical history of diabetes and high blood pressure
- Current vitals are normal except for blood pressure, which is 130/79
- Patient claims his blood pressure ranges from stage 1 to stage 2 hypertension
Current Medications
- Cardizem 180mg ER once a day for hypertension
- Jardiance 25mg once a day for type 2 diabetes
- Tadalafil 5mg once a day for BPH
- Olmesartan Medoxomil/hydrochlorothiazide 40mg-12.5mg once daily for hypertension
- Levothyroxine 125mcg once daily
- Actos 15mg once daily for diabetes
- Tamsulosin 0.4mg once daily for BPH
- Trulicity 4.5mg once weekly for diabetes
- Amaryl 4mg twice daily
- Viagra 100mg PRN every 72 hours
Plan of Care
- According to 3, combination therapy with two or more antihypertensive drugs with a complementary mechanism of action is necessary to achieve aggressive control of blood pressure (<130/80 mm Hg) in patients with diabetes and hypertension
- The patient is already taking Olmesartan Medoxomil/hydrochlorothiazide, which is a fixed-dose combination of an angiotensin receptor blocker and a diuretic, as recommended by 4 and 5
- Studies 4 and 6 suggest that high-dose olmesartan medoxomil (40 mg) plus hydrochlorothiazide is an effective and safe treatment option for controlling blood pressure in patients with mild-to-severe hypertension
- To improve patient compliance and adherence to treatment, simplifying the treatment regimen using well-tolerated, fixed-dose combinations, as suggested by 7, may be beneficial
- Regular monitoring of blood pressure and adjustment of medications as needed to achieve target blood pressure goals (<130/80 mm Hg) is recommended
Potential Adjustments to Current Medications
- Consider increasing the dose of Olmesartan Medoxomil/hydrochlorothiazide or adding another antihypertensive medication to achieve better blood pressure control, as suggested by 3 and 4
- Monitor patient's response to current medications and adjust as needed to minimize potential side effects and improve adherence to treatment, as recommended by 7