What is the next step in managing a 70-year-old patient with episodes of hypotension, currently on amlodipine (calcium channel blocker) 5mg, Atacand (candesartan) 32mg, and metoprolol (beta blocker) 25mg twice daily, with laboratory results showing elevated ferritin, normal vitamin B12, hyponatremia, and impaired renal function?

From the Guidelines

The patient's antihypertensive medications should be gradually reintroduced at lower doses, starting with metoprolol 12.5mg once daily, while closely monitoring blood pressure, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The patient's current presentation of hypotension, in conjunction with their age and medication regimen, necessitates a cautious approach to avoid exacerbating orthostatic hypotension.

• The decision to restart with metoprolol is based on its ability to stabilize blood pressure fluctuations, as noted in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.
• After achieving stable blood pressure readings for 3-5 days, consider adding amlodipine at a reduced dose of 2.5mg daily to minimize the risk of hypotension.
• The Atacand (candesartan) should be withheld until blood pressure stability is achieved with the other medications to avoid potential additive hypotensive effects.
• Regular orthostatic blood pressure measurements should be performed to assess for postural hypotension, as recommended in the 2024 ESC guidelines 1.
• Evaluation of the patient's fluid status is crucial, as volume depletion may contribute to hypotension episodes.
• The patient's medication timing should be adjusted to avoid peak drug effect coinciding with times when hypotensive episodes typically occur, thereby minimizing the risk of orthostatic hypotension.
• Further evaluation of the patient's mildly elevated ferritin level and hyponatremia is necessary to address potential underlying conditions that may be contributing to their hypotensive episodes.
• The patient's age and frailty status should be considered when managing their blood pressure, as the 2024 ESC guidelines recommend maintaining BP-lowering drug treatment lifelong if well tolerated, even beyond the age of 85 years 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Assessment

The patient is a 70-year-old with episodes of hypotension, currently on amlodipine 5mg, atacand 32mg, and metoprolol 25mg BD. The antihypertensives have been withheld for now. Investigations have revealed the following results: Ferritin 778, Vitamin B12 806, sodium 131, and eGFR 69.

Management of Orthostatic Hypotension

According to the study 2, orthostatic hypotension (OH) is an important and common medical problem, particularly in the frail elderly with multiple comorbidities and polypharmacy. The study suggests that angiotensin receptor blockers and calcium channel blockers are preferable antihypertensives for these patients. The patient is currently on amlodipine, which is a calcium channel blocker, and atacand, which is an angiotensin receptor blocker.

Considerations for Antihypertensive Medication

The study 3 found that metoprolol was associated with systolic OH compared to ramipril and amlodipine. This suggests that the patient's current medication regimen may be contributing to their orthostatic hypotension. The study 2 also recommends removing drugs that can worsen OH, including beta-blockers like metoprolol.

Next Steps

Based on the evidence, the next steps could be:

• Reassess the patient's antihypertensive medication regimen and consider alternative medications that may be less likely to exacerbate orthostatic hypotension.
• Monitor the patient's blood pressure and adjust their medication regimen as needed to balance the risk of orthostatic hypotension with the need to control hypertension.
• Consider non-pharmacological interventions to manage orthostatic hypotension, such as increasing fluid and salt intake, wearing compression stockings, and avoiding sudden changes in position.

Additional Considerations

The study 4 found that low diastolic blood pressure (≤ 65 mmHg) was associated with incident hospitalization in nursing home residents. The patient's current sodium level is 131, which is slightly low. Consideration should be given to optimizing the patient's volume status and electrolyte levels to minimize the risk of hypotension.

Potential Interventions

The study 2 suggests that abdominal binders and acarbose may be used to prevent OH and postprandial hypotension, respectively. Additionally, midodrine and droxidopa may be considered if traditional pressor agents are needed. However, these interventions should be tailored to the individual patient's needs and medical history.

Laboratory Results

The patient's laboratory results, including Ferritin 778 and Vitamin B12 806, should be evaluated in the context of their overall medical history and may require additional investigation or management. The patient's eGFR of 69 indicates some degree of renal impairment, which should be taken into account when adjusting their medication regimen.