I have hypertension treated with atenolol, amlodipine, and telmisartan and also have depression and ADHD; I'm experiencing brain fog and peripheral edema—should I discontinue atenolol, keep amlodipine stopped, start chlorthalidone, and switch to an angiotensin‑converting enzyme inhibitor such as enalapril?

Discontinue Atenolol and Switch to Chlorthalidone Plus Telmisartan

You should stop atenolol immediately due to its association with brain fog and cognitive symptoms, keep amlodipine discontinued to resolve peripheral edema, add chlorthalidone as your diuretic, and continue telmisartan rather than switching to enalapril given your history of ACE inhibitor-induced angioedema. 1

Why Stop Atenolol

• Beta-blockers, particularly atenolol, commonly cause central nervous system side effects including fatigue, lethargy, sedation, and cognitive impairment ("brain fog") in 5-10% of patients. 2
• The 2017 ACC/AHA guidelines explicitly state that atenolol should not be used because it is less effective than placebo in reducing cardiovascular events, making it an inferior choice even without the cognitive side effects you're experiencing. 1
• Beta-blockers can exacerbate depression symptoms, which is particularly concerning given your existing depression diagnosis—hydrophilic agents like atenolol were once thought to cause fewer CNS effects, but this has not proven true in clinical practice. 1, 2
• The European Society of Cardiology 2022 guidelines note that beta-blockers can cause confusion and depression, and recommend avoiding them unless there's a specific cardiac indication (post-MI, heart failure, or angina). 1

Why Keep Amlodipine Stopped

• Dihydropyridine calcium channel blockers like amlodipine are the most common cause of peripheral edema among antihypertensive medications, occurring due to preferential arteriolar vasodilation without corresponding venodilation. 1
• The edema from amlodipine is dose-dependent and will not resolve with continued use—discontinuation is the only effective solution. 1
• Your current regimen can achieve adequate blood pressure control without amlodipine by optimizing the combination of telmisartan and chlorthalidone. 3

Why Add Chlorthalidone

• Chlorthalidone is superior to hydrochlorothiazide for cardiovascular outcomes and is the preferred thiazide-like diuretic according to multiple guidelines. 4
• In the landmark ALLHAT trial, chlorthalidone reduced heart failure risk more effectively than amlodipine and was equivalent to lisinopril for blood pressure control. 1
• The combination of an ARB (telmisartan) plus a thiazide-like diuretic (chlorthalidone) is a guideline-recommended first-line dual therapy for hypertension. 1
• A 2023 randomized controlled trial demonstrated that the triple combination of telmisartan 80mg/amlodipine 5mg/chlorthalidone 25mg achieved target BP in 53.8% of patients, but since you need to avoid amlodipine, the dual combination of telmisartan plus chlorthalidone is your optimal strategy. 3

Why Continue Telmisartan (Not Switch to Enalapril)

• You have a documented history of ACE inhibitor-induced angioedema with enalapril—this is an absolute contraindication to all ACE inhibitors. 1
• The ONTARGET study demonstrated that telmisartan was equally effective as the ACE inhibitor ramipril for cardiovascular outcomes but with significantly lower rates of angioedema. 5
• ARBs like telmisartan have a less than 10% cross-reactivity rate with ACE inhibitor-induced angioedema, but given the life-threatening nature of angioedema, continuing telmisartan (which you tolerate) is far safer than risking another ACE inhibitor. 5
• Both ACC/AHA and ESC/ESH guidelines recommend ARBs as equivalent alternatives to ACE inhibitors for hypertension management, with the advantage of better tolerability. 1

Specific Medication Regimen

• Start chlorthalidone 12.5-25mg once daily in the morning (lower dose initially to assess tolerance, can uptitrate to 25mg if needed for BP control). 4, 3
• Continue telmisartan at your current dose (likely 80mg daily based on standard dosing). 3
• Discontinue atenolol immediately—no taper is required for atenolol at typical antihypertensive doses, though monitor for rebound hypertension in the first week. 1
• Keep amlodipine discontinued permanently unless peripheral edema was your only concern and BP remains uncontrolled on dual therapy after 8 weeks. 1

Monitoring and Follow-Up

• Check blood pressure within 1-2 weeks after stopping atenolol to ensure no rebound hypertension. 4
• Monitor serum potassium and creatinine 2-4 weeks after starting chlorthalidone, as thiazide diuretics can cause hypokalemia and may affect renal function. 1
• Reassess BP control at 4-8 weeks—target BP should be <130/80 mmHg per current ACC/AHA guidelines. 1
• Monitor for improvement in cognitive symptoms (brain fog) within 2-4 weeks of stopping atenolol—CNS side effects typically resolve within this timeframe. 2

Special Considerations for Depression and ADHD

• The combination of telmisartan and chlorthalidone has fewer interactions with psychiatric medications compared to beta-blockers or calcium channel blockers. 6, 7
• If you're taking stimulants for ADHD, be aware they can increase blood pressure—ensure your ADHD medication is optimized and not contributing to hypertension. 8
• SSRIs (particularly sertraline) are the preferred antidepressants in patients with hypertension and have minimal interaction with RAS inhibitors and diuretics. 6, 7

Critical Pitfall to Avoid

• Never retry any ACE inhibitor (enalapril, lisinopril, ramipril, etc.) given your documented angioedema history—this is a Class III (harm) recommendation with life-threatening consequences. 1
• Do not add back amlodipine unless absolutely necessary for BP control after maximizing telmisartan and chlorthalidone doses, as the peripheral edema will recur. 1