Should antihypertensive therapy be intensified in an 81‑year‑old woman with hypertension, gastro‑esophageal reflux disease, stage 3 chronic kidney disease, pulmonary fibrosis, and osteoarthritis who is taking albuterol as needed, metoprolol succinate 25 mg daily, losartan potassium 50 mg daily, fenofibrate 145 mg daily, oxybutynin 10 mg daily, and has an elevated systolic blood pressure?

Should Antihypertensive Therapy Be Intensified?

Yes, antihypertensive medication should be increased in this 81-year-old woman with stage 3 CKD and an average blood pressure of 145/70 mmHg. Her systolic blood pressure exceeds guideline targets, and intensification will reduce her cardiovascular and cerebrovascular risk.

Blood Pressure Target for This Patient

• The target BP for this patient is <130/80 mmHg based on the most recent 2024 European Society of Cardiology guidelines, which recommend treating systolic BP to 120-129 mmHg in most adults when well tolerated 1.
• For patients with stage 3 CKD specifically, the 2017 ACC/AHA guidelines support a target of <130/80 mmHg, as patients with CKD were included in SPRINT and derived the same cardiovascular mortality benefit from intensive BP control as those without CKD 1.
• The KDIGO guideline recommends ≤140/90 mmHg for non-proteinuric CKD patients, but acknowledges that lower targets may be appropriate for cardiovascular risk reduction 1.
• At 145/70 mmHg, her systolic BP is above target despite being on two antihypertensive agents (metoprolol succinate 25 mg and losartan 50 mg) 1.

Recommended Medication Adjustment Strategy

Step 1: Optimize Current Renin-Angiotensin System Blockade

• Increase losartan from 50 mg to 100 mg once daily before adding a third agent 2, 3.
• The FDA-approved dosing for losartan in hypertension allows titration up to 100 mg daily as needed for BP control 3.
• This optimization is particularly important given her stage 3 CKD, where RAS blockade provides renoprotection 1.

Step 2: Add a Dihydropyridine Calcium Channel Blocker

• If BP remains ≥140/90 mmHg after optimizing losartan, add amlodipine 5 mg once daily 2, 4.
• The combination of ARB + beta-blocker + dihydropyridine CCB represents guideline-based triple therapy 2.
• Amlodipine provides 10-20 mmHg systolic BP reduction when added to existing therapy, greater than simply increasing doses of current agents 2.
• Start at 5 mg daily in elderly patients to minimize hypotension and pedal edema risk, then titrate to 10 mg if needed 2, 4.
• Dihydropyridine CCBs are specifically endorsed in patients ≥60 years because they do not cause bradycardia and are safe to combine with beta-blockers 2.

Step 3: Consider Thiazide-Like Diuretic if Triple Therapy Insufficient

• If BP remains uncontrolled on losartan 100 mg + metoprolol 25 mg + amlodipine 10 mg, add chlorthalidone 12.5 mg once daily 2.
• Chlorthalidone is preferred over hydrochlorothiazide due to its longer duration (24-72 hours) and superior cardiovascular outcomes 2.
• The preferred triple combination is ARB + CCB + thiazide diuretic according to 2024 ESC guidelines 1.

Special Considerations for This Elderly Patient with CKD

Age-Related Factors

• Antihypertensive therapy should be continued beyond age 85 when well tolerated 1.
• Initial doses and titration should be gradual in elderly patients due to greater risk of adverse effects 4.
• Measure BP in both sitting and standing positions at each visit to detect orthostatic hypotension, which increases fall risk in elderly patients with osteoarthritis 2, 4.
• The target of <130/80 mmHg is appropriate for this fit 81-year-old; systolic 140-150 mmHg is only acceptable in very frail patients ≥80 years 2.

CKD Stage 3 Considerations

• Her stage 3 CKD places her at high cardiovascular risk, making BP control even more critical 1.
• Monitor serum creatinine and potassium 2-4 weeks after increasing losartan dose, as up to 30% creatinine increase is acceptable when optimizing RAS blockade 1, 2.
• The combination of ACE inhibitor and ARB should be avoided due to increased hyperkalemia and acute kidney injury risk without cardiovascular benefit 1.
• Beta-blockers like metoprolol are known to retard CKD progression, though to a lesser degree than RAS blockers 5.

Monitoring Parameters

Intervention	Parameter	Timing	Key Note
Losartan increase to 100 mg	Serum potassium & creatinine	2-4 weeks	Hyperkalemia risk, especially with CKD [2]
Amlodipine addition	Peripheral edema	Each visit	Most common CCB side effect [2,4]
Amlodipine addition	Dizziness/orthostatic symptoms	Each visit	Increased risk in elderly [2,4]
Chlorthalidone (if added)	Serum potassium & creatinine	2-4 weeks	Hypokalemia <3.5 mEq/L eliminates CV protection [2]

Timeline for BP Control

• Achieve target BP within 3 months of initiating or modifying therapy 2.
• Recheck BP within 2-4 weeks after each medication adjustment 4.
• Do not delay therapy escalation when BP ≥140/90 mmHg; act within 2-4 weeks to reduce cardiovascular risk 2.

Critical Pitfalls to Avoid

• Do not increase metoprolol as the primary BP-lowering strategy; beta-blockers are less effective than CCBs or diuretics for stroke prevention in elderly patients 2.
• Do not combine losartan with an ACE inhibitor (dual RAS blockade) due to heightened hyperkalemia and AKI risk without added cardiovascular benefit 1, 2.
• Do not withhold treatment intensification solely based on age; her relatively controlled diastolic BP (70 mmHg) and lack of symptoms suggest she can tolerate further systolic reduction 1, 2.
• Do not use non-dihydropyridine CCBs (diltiazem, verapamil) if heart failure develops, due to negative inotropic effects 2.
• Do not assume treatment failure without confirming medication adherence first, as non-adherence affects 30-75% of older adults 2.

Why Not Simply Increase Current Medications?

• Metoprolol 25 mg daily is already providing adequate dosing for her age and comorbidities; increasing it would provide minimal additional BP reduction and risks excessive bradycardia 2.
• The current metoprolol dose is appropriate for any concurrent rate control needs 2.
• Adding a CCB provides greater BP reduction (10-20 mmHg) than dose escalation of existing agents 2.

Lifestyle Modifications to Reinforce

• Sodium restriction <2 g/day can reduce systolic BP by 5-10 mmHg, especially effective in older adults 2.
• DASH diet provides BP reduction of 11.4/5.5 mmHg 2.
• Weight management if BMI >25 kg/m²; 10 kg loss lowers BP approximately 6/4.6 mmHg 2.
• Aerobic exercise ≥150 min/week moderate intensity reduces BP approximately 4/3 mmHg 2.