What is the next step in managing a 27-year-old female patient with a history of cocaine and alcohol abuse, recently discharged from the hospital 4 days ago after a hypertensive crisis and treated with intravenous (IV) furosemide (Lasix), now on losartan (100 mg), amlodipine (10 mg), and furosemide (40 mg) as needed, presenting with a blood pressure of 140/82?

From the Guidelines

The patient's current antihypertensive regimen of losartan 100 mg daily and amlodipine 10 mg daily should be continued, with close monitoring of her blood pressure, as the current blood pressure of 140/82 mmHg is approaching the recommended target of below 140/90 mmHg, as stated in the 2007 guidelines for the management of arterial hypertension 1. The patient's blood pressure has shown improvement from the hypertensive crisis, but it is still slightly elevated. Since the patient was only discharged 4 days ago, the medications may need more time to reach their full therapeutic effect. Some key points to consider in the management of this patient include:

• Monitoring the patient's blood pressure closely, with home blood pressure monitoring twice daily and keeping a log, to assess the effectiveness of the current regimen.
• Assessing the patient's leg swelling to determine if the as-needed Lasix 40 mg is currently necessary, as this can help guide adjustments to her diuretic therapy.
• Referring the patient to addiction counseling services to address the underlying substance abuse issues, which are critical to her overall health and blood pressure management.
• Scheduling a follow-up appointment within 1-2 weeks to reassess the patient's blood pressure control and medication efficacy, allowing for timely adjustments to her treatment plan.
• Emphasizing lifestyle modifications, including sodium restriction, regular exercise, and complete abstinence from cocaine and alcohol, as these can help improve blood pressure control and reduce cardiovascular risk, as supported by the guidelines 1.
• Educating the patient about symptoms that would warrant immediate medical attention, such as severe hypertension or signs of heart failure, to ensure prompt recognition and treatment of any complications.

From the FDA Drug Label

The usual initial dose of Furosemide tablets for hypertension is 80 mg, usually divided into 40 mg twice a day. To prevent excessive drop in blood pressure, the dosage of other agents should be reduced by at least 50% when Furosemide tablets are added to the regimen As the blood pressure falls under the potentiating effect of Furosemide tablets, a further reduction in dosage or even discontinuation of other antihypertensive drugs may be necessary.

The patient is currently taking losartan 100 mg, amlodipine 10 mg, and 40 mg Lasix daily as needed. Given that the patient's blood pressure is at 140/82, which is not excessively high, and considering the patient was recently discharged from the hospital for hypertensive crisis, it would be prudent to:

• Monitor the patient's blood pressure closely to determine if the current regimen is effective in maintaining a stable blood pressure.
• Adjust the dosage of other antihypertensive agents as needed to prevent excessive drop in blood pressure.
• Consider reducing the dosage of losartan or amlodipine if the patient's blood pressure drops too low. 2

From the Research

Patient Assessment

• The patient is a 27-year-old female with a history of cocaine and alcohol abuse, recently hospitalized for hypertensive crisis and leg swelling.
• She was treated with IV Lasix and discharged on losartan 100 mg, amlodipine 10 mg, and 40 mg Lasix daily as needed.
• Her current blood pressure is 140/82, and she was discharged from the hospital 4 days ago.

Treatment Considerations

• According to the study 3, first-line therapy for hypertension includes lifestyle modification and medication, with a goal of achieving a blood pressure target of <130/80 mm Hg.
• The study 4 suggests that initiating antihypertensive drug treatment when systolic blood pressure is at least 140 mm Hg is a prudent statement, but the evidence is scanty.
• The study 5 found that lower blood pressure targets do not reduce total mortality and may increase the risk of other serious adverse events.

Medication Management

• The patient is currently taking losartan and amlodipine, which are both commonly used to treat hypertension.
• The study 6 compared the ability of losartan and amlodipine to lower blood pressure variability and found that amlodipine may be better at lowering blood pressure variability in essential hypertensive patients.
• The study 7 found that single-pill amlodipine/losartan is superior to losartan monotherapy for controlling blood pressure and is safe and well tolerated in patients with inadequately controlled hypertension.

Next Steps

• Monitor the patient's blood pressure closely and adjust her medication as needed to achieve a blood pressure target of <130/80 mm Hg.
• Consider lifestyle modifications, such as weight loss, healthy dietary pattern, physical activity, and limited alcohol consumption, to help manage her hypertension.
• Continue to monitor the patient for any adverse effects of her medication and adjust her treatment plan as needed.