From the Guidelines
This patient's blood pressure remains uncontrolled despite being on five antihypertensive medications, and I recommend adding spironolactone 25mg daily to her regimen, as she is already on a low dose of spironolactone/hctz, increasing the spironolactone dose is a reasonable next step. Her current medications include a good foundation (ARB, calcium channel blocker, alpha-blocker, beta-blocker, and a weak diuretic combination), but the persistent systolic readings in the 200s indicate resistant hypertension requiring intensification 1. According to the 2024 ESC guidelines, the addition of low-dose spironolactone to existing treatment is recommended for resistant hypertension 1. I would also recommend checking for medication adherence, secondary causes of hypertension (such as renal artery stenosis, primary aldosteronism, or pheochromocytoma), and lifestyle factors including sodium intake, alcohol consumption, and physical activity. Home blood pressure monitoring should be implemented to track response to these medication changes, with a goal of bringing systolic blood pressure below 140mmHg. Laboratory monitoring of electrolytes and renal function should be performed within 2 weeks of these medication changes due to the risk of hypokalemia and worsening renal function with intensified diuretic therapy.
Some key points to consider in the management of this patient's resistant hypertension include:
- Reinforcement of lifestyle measures, especially sodium restriction 1
- Addition of further diuretic therapy if intolerant to spironolactone, with either eplerenone, amiloride, a higher dose thiazide/thiazide-like diuretic, or a loop diuretic 1
- Consideration of catheter-based renal denervation for resistant hypertension patients who have BP that is uncontrolled despite a three BP-lowering drug combination, and who express a preference to undergo renal denervation after a shared risk-benefit discussion and multidisciplinary assessment 1
- The use of single-pill combinations is preferred when combining drugs from different drug classes, as it can lead to greater BP reduction and improve adherence 1.
It is essential to note that the patient's current medication regimen includes a combination of different drug classes, and the addition of spironolactone is a reasonable next step, as recommended by the 2024 ESC guidelines 1. However, it is crucial to closely monitor the patient's response to this medication change and adjust the treatment plan as needed to achieve optimal blood pressure control and minimize potential side effects.
From the FDA Drug Label
The dosage of metoprolol succinate extended-release tablets should be individualized The usual initial dosage is 25 to 100 mg daily in a single dose, whether used alone or added to a diuretic. The dosage may be increased at weekly (or longer) intervals until optimum blood pressure reduction is achieved. In general, the maximum effect of any given dosage level will be apparent after 1 week of therapy. Dosages above 400 mg per day have not been studied
The patient is currently taking metoprolol succinate 25 mg daily. The dosage may be increased at weekly intervals until optimum blood pressure reduction is achieved. Since the patient's blood pressure is still high, the dosage of metoprolol succinate may be increased, but the maximum dosage should not exceed 400 mg per day 2.
From the Research
Patient's Current Medication Regimen
The patient is currently on a multi-drug regimen for hypertension, including:
- Losartan 100mg daily
- Doxazosin 2mg daily
- Amlodipine 10mg daily
- Metoprolol succinate 25mg daily
- Spironolactone/HCTZ 25-25mg daily
Blood Pressure Management
According to 3, the goal for blood pressure management is to achieve a systolic blood pressure (SBP) of less than 130 mmHg and a diastolic blood pressure (DBP) of less than 80 mmHg. The patient's current SBP is in the 200s, which is significantly higher than the recommended target.
Treatment Options
4 discusses the initiation of antihypertensive drug treatment and the target blood pressure levels. The study suggests that antihypertensive agents are well-tolerated, and lowering SBP below 130 mmHg appears to be safe. However, the evidence for specific treatment recommendations is limited.
Amlodipine's Role in Hypertension Management
5 provides an overview of the use of amlodipine in hypertension management. Amlodipine has been shown to be effective in reducing blood pressure and has a favorable safety profile. It is also cost-effective and can be used in patients with various comorbidities, including diabetes and chronic kidney disease.
Response to Antihypertensives
6 examines the blood pressure response to commonly administered antihypertensives in patients with severe inpatient hypertension. The study found that IV hydralazine resulted in the most significant drop in blood pressure, while metoprolol and amlodipine did not lower blood pressure significantly.
Fixed-Dose Combinations
7 compares the effectiveness of fixed-dose combinations of metoprolol and amlodipine in essential hypertension. The study found that the fixed-dose combinations were effective and safe, but not statistically superior to monotherapies.
Key Points
- The patient's current blood pressure is significantly higher than the recommended target.
- Amlodipine is a commonly used and effective antihypertensive agent.
- The response to antihypertensives can vary, and IV hydralazine may be more effective in certain situations.
- Fixed-dose combinations of metoprolol and amlodipine can be effective and safe in managing hypertension.