What is the best course of action for a hypertensive patient with severely elevated blood pressure after taking outdated metoprolol (beta blocker) and experiencing dizziness and nausea?

From the Guidelines

This patient requires immediate management for severe hypertension, and the most recent guidelines from 2024 recommend starting with a combination of two antihypertensive medications from different classes, such as amlodipine and lisinopril, to achieve better blood pressure control and reduce the risk of cardiovascular complications 1. The patient's current blood pressure of 202/128 puts him at significant risk for end-organ damage, and the recent episode of dizziness and nausea after taking the expired metoprolol suggests that this medication may not be suitable for him.

• The patient should be advised to stop taking the expired metoprolol and start a new antihypertensive regimen, with close follow-up within 24-48 hours to reassess blood pressure control.
• The patient should be counseled on the importance of medication adherence and establishing care with a new primary care provider as soon as possible.
• He should also be educated on hypertension complications, including stroke, heart attack, and kidney damage.
• Lifestyle modifications, including sodium restriction, regular exercise, weight management, and stress reduction, should be emphasized as important adjuncts to medication therapy. The 2024 guidelines recommend using single-pill combinations of antihypertensive medications, which can improve adherence and reduce side effects 1.
• The patient's treatment plan should be individualized based on his medical history, lifestyle, and preferences, with regular monitoring of his blood pressure and adjustment of his medication regimen as needed.
• The patient should be advised to monitor his blood pressure at home twice daily and seek emergency care if he develops symptoms like severe headache, vision changes, chest pain, or shortness of breath.

From the FDA Drug Label

Central Nervous System Tiredness and dizziness have occurred in about 10 of 100 patients. Cardiovascular Shortness of breath and bradycardia have occurred in approximately 3 of 100 patients. Gastrointestinal Nausea, dry mouth, gastric pain, constipation, flatulence, and heartburn have been reported in about 1 of 100 patients. Vomiting was a common occurrence.

The patient's symptoms of dizziness and nausea after taking 50 mg of metoprolol are consistent with the adverse reactions reported in the drug label 2.

• Dizziness is a common side effect, occurring in about 10% of patients.
• Nausea is also a reported side effect, occurring in about 1% of patients. Given the patient's history of hypertension and the recent episode of elevated blood pressure, it is essential to monitor the patient's condition closely and consider the potential risks and benefits of continuing metoprolol therapy 2.

From the Research

Patient's Condition

The patient is a 54-year-old male with a past medical history of hypertension, presenting with elevated blood pressure. He had a blood pressure reading of 210/118 at his dentist's office 10 days ago and was advised to follow up with his primary care physician (PCP) before undergoing any dental work.

Medication History

The patient's PCP refilled his amlodipine prescription over the phone, but he has not been seen by that practice in a couple of years. The on-call provider advised him to find a new practice since they had no openings. The patient ran out of amlodipine 2 days ago and took 50 mg of metoprolol, an old prescription from approximately 3 years ago, on the day of presentation.

Current Symptoms

The patient reports a brief episode of dizziness and nausea after taking the metoprolol, but denies any current symptoms, including chest pain, shortness of breath, weakness, headache, vision changes, or speech difficulties. His current blood pressure reading is 202/128.

Relevant Studies

• A study on the effect of fixed-dose combinations of metoprolol and amlodipine in essential hypertension found that these combinations are effective and safe in mild to moderate hypertension 3.
• Research on the effects of dividing amlodipine daily doses on trough drug concentrations and blood pressure control over a 24-hour period found that administering amlodipine in 2 divided doses was not associated with increased trough plasma amlodipine concentrations, reduced arterial stiffness, or improved blood pressure control 4.
• A review of amlodipine in hypertension found that it is a first-line agent with efficacy for improving blood pressure and patient outcomes, and should be considered a first-line antihypertensive agent 5.
• A study on the combination of amlodipine and lisinopril for the treatment of essential hypertension found that the combination had a marked additional effect on blood pressure compared to either drug alone, and that the response to amlodipine tended to be greater the higher the initial blood pressure 6.
• A study on the effects of different antihypertensive drug combinations on blood pressure and arterial stiffness found that various combinations, including those with amlodipine, were equally effective and well-tolerated for reducing blood pressure and improving arterial stiffness in patients with essential hypertension 7.

Key Points

• The patient's elevated blood pressure and history of hypertension require careful management and monitoring.
• The patient's use of metoprolol, an old prescription, may not be the most effective or safe treatment option, and alternative treatments should be considered.
• The patient's current symptoms and medication history should be taken into account when determining the best course of treatment.
• Studies suggest that amlodipine is a effective and safe treatment option for hypertension, and that combination therapy with other antihypertensive agents may be beneficial in certain cases.