How should hypertension be managed in a 77‑year‑old woman taking amlodipine 10 mg daily and losartan 100 mg daily who has a systolic blood pressure in the 150 mm Hg range?

Management of Uncontrolled Hypertension in a 77-Year-Old Woman

Add a thiazide-like diuretic (chlorthalidone or indapamide preferred over HCTZ) to the current regimen of amlodipine 10 mg and losartan 100 mg, as this patient requires triple therapy to achieve blood pressure control. 1

Current Situation Analysis

This patient is on maximally dosed dual therapy (amlodipine 10 mg + losartan 100 mg) with persistent systolic blood pressure in the 150s mmHg range, indicating inadequate control. 2 While there are differing guideline perspectives on blood pressure targets in elderly patients, the weight of evidence supports intensifying therapy at this level.

Blood Pressure Targets in Elderly Patients

The ACC/AHA guidelines recommend a target BP <130/80 mmHg even in patients ≥75 years old, based on the SPRINT trial showing significant reductions in cardiovascular events and mortality with intensive BP control. 1 However, competing guidelines offer different perspectives:

• ACP/AAFP guidelines recommend a more conservative target of <150 mmHg systolic for patients ≥60 years, weighing the SPRINT elderly subgroup data less heavily 1
• ESC/ESH guidelines recommend 130-139 mmHg systolic for patients ≥65 years 1
• British Hypertension Society considers <150/90 mmHg an acceptable "audit standard" minimum for elderly patients 1

Given that this patient's BP remains in the 150s despite maximal dual therapy, treatment intensification is warranted regardless of which guideline framework you follow.

Recommended Third Agent: Thiazide-Like Diuretic

Add chlorthalidone 12.5-25 mg daily or indapamide 1.25-2.5 mg daily as the third agent. 1 The AHA Scientific Statement on Resistant Hypertension specifically recommends thiazide-like diuretics (chlorthalidone or indapamide) over hydrochlorothiazide (HCTZ) because:

• Chlorthalidone lowers BP more effectively than HCTZ, particularly at night 1
• Chlorthalidone has a much longer therapeutic half-life 1
• Both chlorthalidone and indapamide have more cardiovascular disease risk reduction data than HCTZ 1

Why Not Just Increase Current Medications?

Both amlodipine and losartan are already at maximum recommended doses (10 mg and 100 mg respectively). 2 The FDA label for losartan specifies that "the dosage can be increased to a maximum dose of 100 mg once daily," confirming this patient is at the ceiling. 2

Alternative Consideration: Switching Losartan to Combination Product

If you prefer a different approach, consider switching from losartan 100 mg to losartan 50 mg + hydrochlorothiazide 12.5 mg, then titrating to losartan 100 mg + hydrochlorothiazide 25 mg based on response. 2 The FDA label specifically describes this titration strategy for hypertensive patients with left ventricular hypertrophy. 2

However, the thiazide-like diuretics (chlorthalidone/indapamide) are preferred over HCTZ in the combination product for the reasons stated above. 1

Monitoring and Titration Strategy

• Reassess BP within 2-4 weeks after adding the third agent 3
• Allow at least 4 weeks to observe full response before further adjustments 1
• Check both sitting and standing BP to assess for orthostatic hypotension, which is more common in elderly patients 1, 4
• Monitor for symptomatic hypotension: dizziness, lightheadedness, weakness, or falls 4

Dose Titration for Elderly Patients

Start with lower doses and titrate gradually in elderly patients. 1 For chlorthalidone, begin with 12.5 mg daily and increase to 25 mg if needed after 4 weeks. Initial doses should be more gradual because of greater chance of adverse effects in this age group. 1

Critical Pitfalls to Avoid

Do not hold or reduce current medications simply because the patient is elderly and BP is "only" in the 150s. The LIFE trial demonstrated that in 55-80 year old hypertensive patients, including those with isolated systolic hypertension, aggressive BP lowering reduced cardiovascular events, particularly stroke. 1

Do not delay adding the third medication while "waiting to see" if the current regimen will eventually work. At BP ≥150/90 mmHg on dual therapy, evidence shows that triple therapy is needed to achieve adequate control, and delayed control increases cardiovascular risk exposure. 3

Monitor electrolytes (particularly potassium and sodium) within 2-4 weeks after adding a diuretic, especially given the concurrent ARB therapy. 1

Check renal function, as the combination of ARB + calcium channel blocker + diuretic requires monitoring for changes in creatinine and estimated GFR. 1

Special Considerations for This Patient Population

Research evidence confirms that combination therapy with amlodipine + ARB (like losartan) provides complementary mechanisms and is effective in elderly patients, with the addition of a diuretic as the logical third step. 5, 6 Studies specifically in elderly patients show that amlodipine-based regimens are well-tolerated and effective at reducing systolic BP. 7, 8

African American or Hispanic patients may require more aggressive combination therapy, as research shows these populations often need multiple agents to achieve BP control. 6