In a 77‑year‑old woman with hypertension uncontrolled on amlodipine 10 mg daily and losartan 100 mg daily (seated systolic ~150 mm Hg) who has urinary incontinence, what is the most appropriate third antihypertensive agent that minimizes worsening incontinence?

Chlorthalidone and Urinary Incontinence in Elderly Women

You are correct to be concerned—adding chlorthalidone will likely worsen her incontinence, and a calcium channel blocker (amlodipine 5–10 mg daily) is the most appropriate third agent for this 77‑year‑old woman.

Why Chlorthalidone Worsens Incontinence

• Thiazide and thiazide‑like diuretics cause nocturia, poor sleep, and urinary frequency through increased urine production, and the European Society of Cardiology explicitly cautions that these agents are potentially inappropriate in elderly patients (≥75 years) with urinary incontinence. 1
• Diuretics increase bladder filling frequency and urgency, directly exacerbating both stress and urge incontinence in older women who already have compromised pelvic‑floor function. 1
• The 2022 ESC Working Group on Cardiovascular Pharmacotherapy specifically lists diuretics as requiring caution in patients with poor mobility or urinary incontinence. 1

The Preferred Third Agent: Amlodipine

• Add amlodipine 5 mg once daily, titrating to 10 mg after 2–4 weeks if needed, to achieve the guideline‑recommended triple therapy of ARB + CCB + ACE‑inhibitor‑equivalent (losartan + amlodipine). 2
• Calcium channel blockers are weight‑neutral, do not affect bladder function, and do not cause urinary frequency or nocturia, making them ideal for elderly women with incontinence. 2
• The combination of losartan 100 mg + amlodipine 10 mg provides complementary vasodilation through calcium‑channel blockade and renin‑angiotensin inhibition, with superior blood‑pressure control compared to either agent alone. 2
• Amlodipine may actually reduce peripheral edema when combined with an ARB, and it does not worsen incontinence. 2

Evidence Supporting Amlodipine Over Diuretics in This Context

• A 1998 case report documented that switching from an alpha‑blocker (which caused stress incontinence) to an ACE inhibitor (which caused cough‑induced stress incontinence) and finally to amlodipine resolved both the cough and the stress incontinence, demonstrating that calcium channel blockers do not adversely affect lower urinary tract function. 3
• In elderly hypertensive patients (65–73 years), amlodipine 2.5–10 mg daily achieved significant blood‑pressure reductions (systolic 171 → 149 mm Hg, diastolic 100 → 90 mm Hg) with good tolerability and no reports of urinary symptoms. 4

Blood‑Pressure Targets and Monitoring

• Target blood pressure is <140/90 mm Hg minimum, ideally <130/80 mm Hg if well tolerated in this 77‑year‑old woman. 2, 5
• Re‑measure blood pressure 2–4 weeks after adding amlodipine, with the goal of achieving target within 3 months. 2, 5
• Monitor for orthostatic hypotension by checking blood pressure in both sitting and standing positions, as elderly patients have increased risk. 5

If Blood Pressure Remains Uncontrolled on Triple Therapy

• If blood pressure stays ≥140/90 mm Hg despite losartan 100 mg + amlodipine 10 mg, only then consider adding spironolactone 25 mg daily as the preferred fourth‑line agent for resistant hypertension, which provides additional reductions of approximately 20–25/10–12 mm Hg. 2
• Spironolactone addresses occult volume expansion that commonly underlies treatment resistance, but it should be reserved for true resistant hypertension after optimizing the ARB + CCB combination. 2
• Check serum potassium and creatinine 2–4 weeks after initiating spironolactone because of hyperkalemia risk when combined with losartan. 2

Critical Pitfalls to Avoid

• Do not add a thiazide diuretic as the third agent in this elderly woman with urinary incontinence—the ESC explicitly warns against this practice. 1
• Do not add a beta‑blocker unless there are compelling indications (angina, post‑MI, heart failure, atrial fibrillation), as beta‑blockers are less effective than calcium channel blockers for stroke prevention and cardiovascular events. 2
• Do not delay treatment intensification—her systolic pressure of ~150 mm Hg requires prompt action within 2–4 weeks to reduce cardiovascular risk. 2

Lifestyle Modifications to Augment Pharmacotherapy

• Sodium restriction to <2 g/day yields a 5–10 mm Hg systolic reduction and enhances the efficacy of both ARBs and calcium channel blockers. 2
• Weight loss (if BMI ≥25 kg/m²)—losing ~10 kg reduces blood pressure by approximately 6/4.6 mm Hg. 2
• Regular aerobic exercise (≥30 minutes most days) lowers blood pressure by ~4/3 mm Hg. 2
• Limit alcohol to ≤1 drink per day for women to avoid interference with blood‑pressure control. 2