In an elderly man with BPH (benign prostatic hyperplasia) undergoing TURP (transurethral resection of the prostate) under SA (spinal anaesthesia) and uncontrolled hypertension on amlodipine 5 mg and atenolol 50 mg daily, should I add a nighttime 5 mg dose of amlodipine?

Management of Uncontrolled Hypertension in an Elderly BPH Patient Scheduled for TURP

Adding amlodipine 5 mg at night to your current regimen of amlodipine 5 mg + atenolol 50 mg in the morning is a reasonable approach for this elderly patient with uncontrolled hypertension scheduled for TURP, though optimizing the existing regimen or adding a different drug class may be more effective.

Perioperative Blood Pressure Management

Blood pressure levels of 180/110 mm Hg or greater should be controlled prior to surgery. 1 Your patient's current uncontrolled hypertension requires immediate attention before proceeding with TURP under spinal anesthesia.

• Patients with controlled hypertension should maintain their medications until the time of surgery, and therapy should be reinstated as soon as possible postoperatively 1
• Uncontrolled hypertension is associated with wider fluctuations of BP during induction of anesthesia and intubation, and may increase the risk for perioperative ischemic events 1
• Patients with hypertension demonstrate a more labile haemodynamic profile than their non-hypertensive counterparts, with pronounced increases in sympathetic activation during airway instrumentation 1

Optimal Antihypertensive Strategy

Why Your Current Plan Has Limitations

Simply adding another 5 mg dose of amlodipine at night provides only modest additional benefit—approximately 1.6/3.3 mm Hg reduction—whereas adding a second drug class yields 10-20 mm Hg systolic reduction. 2

• Combination therapy with agents from different classes is more effective than dose escalation within the same class 2
• The maximum recommended dose of amlodipine is 10 mg daily, so splitting to 5 mg twice daily is within guidelines but may not achieve adequate control 2

Recommended Approach: Add a Thiazide Diuretic or ACE Inhibitor/ARB

For this patient, adding a thiazide-like diuretic (chlorthalidone 12.5-25 mg daily) or an ACE inhibitor/ARB would be more effective than simply increasing amlodipine. 2

• The combination of calcium channel blocker + ACE inhibitor/ARB + thiazide diuretic represents guideline-recommended triple therapy 2
• Since the patient is already on a beta-blocker (atenolol), adding a thiazide diuretic would create an effective three-drug regimen 2
• Chlorthalidone is preferred over hydrochlorothiazide due to superior 24-hour BP control and cardiovascular outcome data 2

Special Considerations for BPH and TURP

Alpha-Blockers: Dual Benefit

Nonsurgical treatment of patients with urinary outflow obstruction includes the use of α1-blockers such as terazosin, doxazosin, or prazosin, which indirectly dilate prostatic and urinary sphincter smooth muscle and also lower BP. 1

• Alpha-blockers like doxazosin or terazosin could address both hypertension and BPH symptoms simultaneously 3
• However, these may cause orthostatic hypotension, especially when combined with other antihypertensives 4
• Tamsulosin achieves prostatic smooth muscle relaxation without significant blood pressure effects, making it safer when combined with other antihypertensives 4

Perioperative Medication Management

Atenolol should be continued throughout the perioperative period, as beta-blockade provides cardiovascular protection during surgery. 1

• Older patients may gain particular benefit from treatment with β1-selective beta-blockers before and during the perioperative period 1
• ACE inhibitors/ARBs may be omitted on the morning of surgery, taking into consideration the patient's blood pressure 1
• If ACE inhibitors/ARBs are given, careful hemodynamic monitoring and appropriate volume replacement are necessary 1

Practical Algorithm for This Patient

Immediate (Before Surgery):

1. Check serum creatinine (you noted it's not available—this is essential before adding any antihypertensive) 2
2. Measure blood pressure multiple times to confirm true uncontrolled hypertension and rule out white-coat effect 2
3. Verify medication adherence as non-adherence is the most common cause of apparent treatment resistance 2

Medication Adjustment Options (in order of preference):

Option 1 (Most Effective): Add chlorthalidone 12.5-25 mg once daily in the morning to create a three-drug regimen (atenolol + amlodipine + chlorthalidone) 2

• Check potassium and creatinine 2-4 weeks after initiation 2
• Target BP <140/90 mm Hg minimum, ideally <130/80 mm Hg 2

Option 2 (Your Proposed Plan): Increase amlodipine to 10 mg daily (either as 10 mg once daily or 5 mg twice daily) 2

• This provides modest additional benefit but may not achieve adequate control 2
• Reassess in 2-4 weeks 2

Option 3 (If Creatinine Normal): Add an ACE inhibitor (lisinopril 10 mg) or ARB (losartan 50 mg) 2

• Provides complementary mechanism to calcium channel blocker 2
• Monitor potassium and creatinine 1-2 weeks after initiation 2

Timing Considerations:

• For elective surgery, effective BP control can be achieved over several days to weeks of outpatient treatment 1
• Do not proceed with TURP if BP remains ≥180/110 mm Hg 1
• Reassess BP 2-4 weeks after medication adjustment, with goal of achieving target within 3 months 2

Critical Pitfalls to Avoid

• Do not add a second beta-blocker—this provides no additional benefit for BP control 2
• Do not combine an ACE inhibitor with an ARB—this increases adverse events without additional cardiovascular benefit 2
• Do not delay treatment intensification—uncontrolled hypertension increases perioperative risk 1
• Do not assume treatment failure without confirming adherence and ruling out secondary causes 2
• Monitor for TURP syndrome postoperatively—hyponatremia can occur with glycine irrigation and presents with bradycardia, hypotension, confusion, and coma 5, 6

Monitoring Parameters

• Target BP: <140/90 mm Hg minimum before surgery 1
• Check electrolytes (sodium, potassium) and creatinine before adding diuretic or ACE inhibitor/ARB 2
• Reassess BP 2-4 weeks after medication change 2
• Continue all antihypertensives through the morning of surgery except possibly ACE inhibitors/ARBs 1