From the Guidelines
For this 61-year-old female patient with uncontrolled hypertension (BP 168/94) despite current therapy with atenolol 25 mg daily and HCTZ 25 mg daily, I would recommend increasing the dose of atenolol to 50 mg daily, as it is within the recommended dose range of 25-100 mg daily, according to 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.
Rationale for Recommendation
The patient's current dose of atenolol is at the lower end of the therapeutic range, and increasing it to 50 mg daily may help achieve better blood pressure control. The guideline suggests that beta-blockers like atenolol can be used as secondary agents, and the recommended dose range is 25-100 mg daily, taken twice daily 1.
Considerations and Monitoring
When increasing the atenolol dose, the patient should be monitored for potential side effects such as bradycardia, fatigue, or bronchospasm. It is also essential to assess the patient's response to the increased dose and adjust the treatment plan accordingly. If the patient does not achieve adequate blood pressure control with this adjustment, the next step might be to add a third agent from a different class, such as an ACE inhibitor or calcium channel blocker, rather than further increasing either current medication.
Alternative Options
Other options, such as adding a secondary agent like eplerenone or spironolactone, could be considered if the patient's blood pressure remains uncontrolled despite the increased atenolol dose. However, these agents are typically preferred in patients with primary aldosteronism or resistant hypertension, and their use should be carefully evaluated based on the patient's individual needs and medical history 1.
Key Points
- Increase atenolol dose to 50 mg daily to achieve better blood pressure control
- Monitor patient for potential side effects and adjust treatment plan as needed
- Consider adding a third agent from a different class if blood pressure remains uncontrolled
- Evaluate patient's individual needs and medical history before adding secondary agents like eplerenone or spironolactone 1.
From the FDA Drug Label
DOSAGE & ADMINISTRATION Hypertension The initial dose of atenolol is 50 mg given as one tablet a day either alone or added to diuretic therapy. ... If an optimal response is not achieved, the dosage should be increased to atenolol 100 mg given as one tablet a day
- The patient is currently taking atenolol 25 mg daily, which is lower than the recommended initial dose of 50 mg daily.
- Increasing the dosage of atenolol to 50 mg daily or 100 mg daily may help to decrease the patient's blood pressure.
- Since the patient is already taking HCTZ 25 mg daily, increasing the dose of atenolol would be a suitable option to try to achieve better blood pressure control 2.
From the Research
Patient's Current Medication and Condition
The patient is a 61-year-old female with a history of hypertension, currently managed with atenolol 25 mg daily and HCTZ 25 mg daily. Her current blood pressure is 168/94 mmHg.
Potential Medication Adjustments
To decrease the patient's blood pressure, the following options could be considered:
- Increasing the dose of atenolol or HCTZ
- Adding a new medication to the current regimen
Evidence-Based Options
Based on the provided studies, the following options could be considered:
- Adding an ACE inhibitor, such as lisinopril, to the current regimen 3, 4, 5
- Adding an ARB (angiotensin receptor blocker) to the current regimen, although the evidence for this is weaker compared to ACE inhibitors 6
- Considering alternative medications, such as amlodipine, although the evidence for this is limited to a comparison with atenolol 7
Key Findings
- The addition of lisinopril to atenolol therapy has been shown to produce a significant reduction in blood pressure 3, 4, 5
- The combination of an ACE inhibitor and a beta-blocker may be as effective as the combination of a diuretic and a beta-blocker in reducing blood pressure 4
- ARBs may cause slightly fewer withdrawals due to adverse effects compared to ACE inhibitors, although the evidence for their efficacy in reducing mortality and morbidity is weaker 6