What can be done to improve stage 2 hypertension in a 72-year-old female patient on losartan (angiotensin II receptor antagonist) 25mg daily and propranolol (beta blocker) 20mg twice weekly for liver cirrhosis, who has bradycardia?

From the Guidelines

To improve blood pressure control in this 72-year-old female patient with stage 2 hypertension and liver cirrhosis, I recommend increasing the losartan dose to 50mg daily while discontinuing the propranolol, as the current regimen is inadequate and propranolol is likely contributing to her bradycardia. The patient's current losartan dose of 25mg daily is at the lower end of the recommended starting dose range of 25-50mg, and uptitration is often necessary to achieve adequate blood pressure control 1. Additionally, the patient's propranolol dose of 20mg twice weekly is not only contributing to her bradycardia but also may not be sufficient for adequate portal pressure reduction in the context of liver cirrhosis.

The management of portal hypertensive gastropathy (PHG) in patients with cirrhosis involves reducing portal pressure, and nonselective beta-blockers like propranolol can be effective in some patients 1. However, in this case, the patient's bradycardia and inadequate blood pressure control suggest that alternative strategies should be considered.

After discontinuing propranolol, if the patient's heart rate normalizes and blood pressure remains elevated, consider adding amlodipine 5mg daily, which is generally well-tolerated in liver disease. Close monitoring of blood pressure, heart rate, and renal function is essential after these changes, and the patient should be reassessed in 2-4 weeks. This approach prioritizes the patient's blood pressure control while minimizing potential adverse effects on her liver disease. The 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults recommends initiating pharmacological therapy for stage 2 hypertension with one or two antihypertensive agents of different classes, and losartan and amlodipine are reasonable choices in this context 1.

From the FDA Drug Label

2.1 Hypertension Adult Hypertension The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure [see CLINICAL STUDIES (14.1)]. 2.4 Dosage Modifications in Patients with Hepatic Impairment In patients with mild-to-moderate hepatic impairment the recommended starting dose of losartan is 25 mg once daily.

The patient is currently taking losartan 25mg daily, which is the recommended starting dose for patients with mild-to-moderate hepatic impairment. Considering the patient has liver cirrhosis and is still stage 2 hypertensive, the dosage of losartan can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure. However, given the patient's bradycardia in the high 40s to low 50s, caution should be exercised when increasing the dose of losartan, as it may further lower blood pressure and potentially worsen bradycardia. The patient's propranolol dose may also need to be adjusted to balance blood pressure control with heart rate considerations 2.

• Key considerations:
  • Increase losartan dose to control blood pressure
  • Monitor and adjust propranolol dose as needed to avoid exacerbating bradycardia
  • Closely monitor patient's blood pressure and heart rate during dosage adjustments.

From the Research

Patient Management

To improve the management of the 72-year-old female patient with stage 2 hypertension, the following options can be considered:

• The patient is currently on losartan 25mg daily and propranolol 20mg twice weekly for liver cirrhosis, but still has stage 2 hypertension. According to 3, calcium channel blockers are the mainstay of treatment for hypertension in liver transplant patients due to their potent vasodilatory effects.
• The patient has bradycardia in the high 40s to low 50s, which may be a concern when adding or adjusting beta-blockers. However, 3 suggests that beta-blockers may be considered first-line drugs in patients with resting tachycardia and in those with high cardiac outputs.
• Adding a diuretic to the patient's current regimen may be beneficial, as shown in 4, where the combination of losartan and hydrochlorothiazide was effective in reducing blood pressure.

Treatment Options

The following treatment options can be considered:

• Adding a calcium channel blocker, such as amlodipine, to the patient's current regimen, as suggested by 3.
• Increasing the dose of losartan or adding a diuretic, such as hydrochlorothiazide, as shown in 4 to be effective in reducing blood pressure.
• Considering the use of other antihypertensive classes, such as angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, as mentioned in 5 and 6.

Monitoring and Education

It is essential to:

• Monitor the patient's blood pressure regularly and adjust the treatment regimen as needed, as suggested by 5 and 6.
• Educate the patient on lifestyle modifications, such as diet and exercise, to help manage hypertension, as mentioned in 5.
• Be aware of potential side effects, such as ankle edema, which was the most frequent side effect of therapy in 5, and losartan-induced hepatic injury, as reported in 7.