From the Guidelines
For a 69-year-old African American male with elevated systolic blood pressure in the 150s despite amlodipine 10 mg daily, I recommend adding a thiazide diuretic such as chlorthalidone 12.5-25 mg daily or hydrochlorothiazide 12.5-25 mg daily. This recommendation is based on the most recent and highest quality study available, which suggests that thiazide diuretics are particularly effective in African American patients and work well in combination with calcium channel blockers like amlodipine 1. The combination of a thiazide diuretic and a calcium channel blocker addresses both volume-dependent and vasoconstrictive components of hypertension, providing a comprehensive approach to blood pressure management. Some key points to consider when initiating this new medication include:
- Starting at a lower dose and titrating up as needed to minimize side effects
- Monitoring for electrolyte abnormalities with thiazides or dizziness with ARBs
- Rechecking blood pressure within 2-4 weeks of starting the new medication to assess efficacy and adjust dosing if necessary
- Aiming for a goal blood pressure below 130/80 mmHg, though individual targets may vary based on comorbidities and tolerance. Alternatively, adding an angiotensin receptor blocker (ARB) like losartan 50-100 mg daily could be considered, though ACE inhibitors and ARBs may be slightly less effective as monotherapy in African American patients 1. However, the most recent guideline from 2020 suggests that for black patients, a combination of a low-dose ARB and a DHP-CCB or DHP-CCB thiazide-like diuretic is a reasonable approach 1. Overall, the choice of medication should be individualized based on the patient's specific needs and medical history.
From the Research
Alternative Blood Pressure Medications
For a 69-year-old African American male taking amlodipine 10 mg qd with elevated blood pressures in the 150s systolic, alternative medications can be considered to achieve better blood pressure control.
- The patient is already on amlodipine, a calcium channel blocker, and may benefit from adding another medication to their regimen.
- A fixed-dose combination of losartan and hydrochlorothiazide has been shown to improve endothelial function in patients with uncontrolled hypertension despite taking low-dose amlodipine 2.
- Losartan, an angiotensin II receptor blocker (ARB), can be considered as an add-on therapy to amlodipine.
- Hydrochlorothiazide, a diuretic, can also be considered as an add-on therapy to amlodipine.
Considerations for Elderly Patients
When treating hypertension in elderly patients, it is essential to consider the potential effects of medications on this population.
- Amlodipine has been shown to be effective and well-tolerated in elderly patients with mild to moderate hypertension 3.
- The pharmacokinetics and pharmacodynamics of amlodipine in elderly patients have been studied, and the results suggest that elderly patients may require lower doses due to decreased clearance and prolonged elimination half-life 4.
Potential Add-on Therapies
Based on the available evidence, potential add-on therapies to amlodipine for this patient include:
- Losartan, an ARB, which has been shown to improve endothelial function when combined with hydrochlorothiazide 2.
- Hydrochlorothiazide, a diuretic, which can be used in combination with losartan to achieve better blood pressure control.
- Other medications, such as ACE inhibitors or beta-blockers, may also be considered, but the evidence for their use in this specific patient population is limited.