What is the emergency room management of a patient with stage 2 hypertension, currently on Irbesartan (Angiotensin II receptor antagonist) 150mg, with a history of ulcerative colitis on Mesalazine (Aminosalicylate)?

From the Guidelines

For a patient with a blood pressure of 169/84 mmHg in the ER who is currently on irbesartan 150mg and has ulcerative colitis treated with mesalazine, I recommend increasing the irbesartan dose to 300mg daily and adding amlodipine 5mg daily, as this patient has stage 2 hypertension requiring prompt management, according to the 2020 international society of hypertension global hypertension practice guidelines 1. The current irbesartan dose is suboptimal, and maximizing the ARB before adding another agent is reasonable. Amlodipine is a good choice as a second agent because calcium channel blockers work well with ARBs and have neutral effects on inflammatory bowel disease.

Key Considerations

• Avoid NSAIDs as they can worsen both hypertension and ulcerative colitis, as suggested by the management of inflammatory bowel disease in the emergency setting guidelines 1.
• Also avoid diuretics if possible as they may exacerbate electrolyte abnormalities in patients with active colitis.
• The patient should follow up within 2-4 weeks to reassess blood pressure control.
• If blood pressure remains elevated, consider adding a third agent such as a low-dose thiazide diuretic if the ulcerative colitis is well-controlled.
• The goal blood pressure should be <130/80 mmHg, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1.
• Lifestyle modifications including sodium restriction, regular exercise, and stress management should be emphasized alongside medication adjustments.

Management of Hypertension

According to the esc council on hypertension position document on the management of hypertensive emergencies 1, patients who lack acute hypertension-mediated end organ damage do not have a hypertensive emergency and can usually be treated with oral BP-lowering agents and usually discharged after a brief period of observation. This patient's blood pressure is elevated, but there is no mention of acute organ damage, so oral medication adjustment is appropriate.

Ulcerative Colitis Considerations

The wses-aast guidelines: management of inflammatory bowel disease in the emergency setting 1 suggest evaluating all hemodynamically stable patients presenting with acute severe ulcerative colitis in a multidisciplinary approach with the gastroenterologist to decide on options for initial medical treatment. However, this patient's ulcerative colitis is being treated with mesalazine, and the primary concern is managing the hypertension.

From the Research

ER Management of Hypertension

The patient's blood pressure is 169/84 mmHg, and they are currently taking irbesartan 150mg for hypertension, with a history of ulcerative colitis and mesalazine treatment.

• The patient's current blood pressure is elevated, but not severely so, according to the study 2.
• Irbesartan, an angiotensin receptor blocker (ARB), has been shown to be effective in lowering blood pressure, with a high efficacy comparable to ACE inhibitors and superior to other ARBs such as losartan and valsartan 3.
• The study 4 found that ARBs, including telmisartan, had the same successful reduction of systolic blood pressure (SBP) as beta blockers and calcium channel blockers.
• For patients with mild hypertension, lifestyle modifications and out-of-office monitoring may be recommended before starting or adjusting drug treatment, according to the study 5.
• Calcium channel blockers, which can be used in combination with other drugs to lower blood pressure, are effective across all patient groups, regardless of sex, race/ethnicity, age, and dietary sodium intake 6.

Treatment Considerations

• The patient's current medication, irbesartan, is an ARB, which has been shown to be effective in lowering blood pressure and has a lower side effect profile compared to other drug classes 3.
• The study 2 suggests that intravenous antihypertensive therapy may not be necessary for patients with asymptomatic, uncontrolled blood pressure, and that oral regimens can be intensified instead.
• The patient's history of ulcerative colitis and mesalazine treatment should be considered when adjusting their medication regimen, although there is no direct evidence in the provided studies to suggest a specific interaction between mesalazine and antihypertensive medications.

Monitoring and Adjustments

• The patient's blood pressure should be closely monitored, and their medication regimen adjusted as needed to achieve optimal blood pressure control 5.
• The study 4 found that all three antihypertensive medication groups (beta blockers, calcium channel blockers, and ARBs) had the same successful reduction of SBP, suggesting that the choice of medication may depend on individual patient factors.