What is the emergency room management of a 63-year-old female (YOF) with hypertension, on irbesartan (Angiotensin II receptor antagonist) 150mg/day, who also has ulcerative colitis on mesalazine (5-aminosalicylic acid)?

From the Guidelines

For this 63-year-old female with elevated blood pressure (169/84) on irbesartan 150mg daily who also has ulcerative colitis on mesalazine, I recommend increasing her irbesartan dose to 300mg daily while continuing her mesalazine therapy, as her current blood pressure indicates inadequate control on the present dose, and irbesartan can be safely titrated up to 300mg daily for better hypertension management 1.

Key Considerations

• Her ulcerative colitis appears to be appropriately managed with mesalazine, which doesn't typically interact significantly with irbesartan, as per the AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis 1.
• It's essential to avoid NSAIDs for pain or blood pressure management as these can exacerbate her gastrointestinal condition.
• Close monitoring of her renal function and electrolytes within 1-2 weeks after dose adjustment is necessary, as angiotensin receptor blockers like irbesartan can affect kidney function.
• If her blood pressure remains elevated despite the increased irbesartan dose, adding a calcium channel blocker like amlodipine 5mg daily would be a reasonable next step, as this combination works well and has minimal impact on inflammatory bowel disease.

Lifestyle Modifications

• Lifestyle modifications including sodium restriction, regular exercise, and stress management should also be emphasized as part of her comprehensive hypertension management plan.
• The patient's current blood pressure does not indicate a hypertensive emergency, as defined by the ESC Council on Hypertension position document on the management of hypertensive emergencies, which typically involves very high BP values (often >200/120 mmHg) with advanced retinopathy, acute renal failure, and/or thrombotic microangiopathy (TMA) 1.

From the Research

ER Management of Hypertension

• The patient is a 63-year-old female with a blood pressure of 169/84 mmHg, who is currently taking irbesartan 150mg/day 2, 3.
• Irbesartan is an angiotensin II receptor blocker (ARB) that has been shown to have metabolic, anti-inflammatory, and antioxidative effects in patients with high-risk hypertension 4.
• The patient's current blood pressure is not adequately controlled, and combination therapy with a calcium channel blocker (CCB) such as amlodipine may be considered to improve blood pressure control 3, 5, 6.

Considerations for Combination Therapy

• Combination therapy with an ARB and a CCB has been shown to be effective in reducing blood pressure and improving cardiovascular outcomes 2, 3, 5, 6.
• The fixed-dose combination of irbesartan and amlodipine has been shown to be well-tolerated and effective in reducing blood pressure in patients with hypertension not adequately controlled with monotherapy 3, 6.
• The patient's ulcerative colitis, which is being treated with mesalazine, should be considered when selecting a combination therapy, as some medications may interact with mesalazine or exacerbate the patient's condition.

Potential Next Steps

• Consider adding amlodipine to the patient's current irbesartan regimen to improve blood pressure control 3, 6.
• Monitor the patient's blood pressure and adjust the dosage as needed to achieve adequate control.
• Consider the patient's overall health status, including their ulcerative colitis, when selecting a combination therapy and monitoring for potential side effects 2, 3, 5, 4, 6.