Best HTN treatment for this patient?

Angioedema associated with ACE-Inhibitors is more common in African Americans.

Consult with your preceptor or pull up current HTN guidelines and that should lead you down the right path.

Did the patient try lasix or a HCTZ? That could be a first option.

The patient can also go with a nitrate/hydralazine combination such as bidil. Those have proven efficacy with african americans.

Also, if the swelling was found to be due to amlodipine, that shouldn't be a problem to withdraw the drug.

The incidence of edema with amlodipine is pretty high...like 5-15% I wanna say.


Google "jnc7"

Time for the prescriber to look at some guidelines. I'm surprised for an African-American pt with no compelling indications, a dr would go for an ACEI 1st.

For HTN with no compelling indications, a diuretic would be the 1st choice, and they're cheaper.

http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

shroomysoup said:

The patient is an African American and has already tried amlodipine, but his BP was not controlled on it and he also got swelling while on it. He's been on lisinopril 20 mg daily for 3 weeks and his blood pressure is 150/100.

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If ACEI is the only anti-HTN used in AA or the elderly, then it is not as effective. I would also switch him to HCTZ as the initial drug. How old is he? What was his BP before he started lisinopril? If he's like 75 and if his BP is not significantly above the normal range, then he may not even need an anti-HTN drug.

Yup for thiazides, probably lasix 20mg going to 40mg might be a better choice. Or HCTZ 25mg.

But also what his Dx? There must be something else going... HTN is usually a sign for something else...

Dietary wise... everyone knows salt restriction but interestingly... "Degree of reduction in sodium intake and change in blood pressure were not related."
http://www.bmj.com/cgi/content/abstract/325/7365/628

shroomysoup said:

Sorry guys, I forgot to mention that the patient is also on HCTZ 25 mg daily, so he needs something else!

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At least give us age, other disease states and medications!

Metoprolol, depending on other disease states

What is the pt's age? If under 60, I'd second the metoprolol.

I would add it to the lisinopril. Patients often require 2, 3, maybe 4 drugs to control BP. Might want to watch out for the hypercholesterolemia, but it shouldn't be a big deal.

I'd add metoprolol to the lisinopril. When it comes to combining antiHTN drugs, patients benefit from an additive antiHTN effect, but the side effects are less than additive. So you are better off taking more drugs at lower doses than fewer drugs at higher doses.

Has anybody done a Framingham risk score on this pt? I'm just thinking the 20mg simvastatin is kinda wussy.

I agree Pharmagirl, that statin dose is like throwing a feather at a bull hoping he stops. I'm also too far behind to pull out my notes, since I haven't had to classify anyone and I'm horrible at retaining that kinda junk.

I assume that you've already covered diet, exercise, proper medication usage (i.e. is he really taking it?) and other lifestyle changes that have to be made, because you can throw all the drugs you want at a problem if the guy's still downing sodas, eatting chips, fries and fast food every day, what's the point?

I agree I'd throw on a betablocker, metoprolol 50mg would be a logical next step. You get your biggest bang for your buck introducing the drug, not by turning it up. You're at a middle dose of lisinopril, I wouldn't expect a lot of improvement by taking him to 40mg.

As for your second question, from my personal and highly biased experience (well really my family's) amlodipine sucks nuts for a pure BP drug, there are so many better drugs out there.

do you own homework and look at the JNC7 guidelines for treatment of hypertension !

I'd up the lisinopril to 40 QD rather than going straight to metoprolol. If that doesn't work, then move on to a beta blocker if he can tolerate it.

Beta blockers are least effective in those with low renin levels...generally meaning elderly or African American patients.

none of you guys are down with chlorthalidone?

if that doesn't do the trick..i'd consider addig the acei..after that i'd try the amlodipine again..the acei may decrease the swelling...

UMN_MJS_2010 said:

do you own homework and look at the JNC7 guidelines for treatment of hypertension !

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Ya know?


Instructor: What evidence do you have to support your recommendation?
Student: I got it from a forum on the internet

No one on this board can possibly give you a recommendation. Only you have access to the pt's history...I mean come on?

YOU DIDN'T EVEN GIVE US A COMPLETE MEDICATION HISTORY AT FIRST!!!

THE FIRST THING A PHARMACIST SHOULD DO IS ASSESS ADHERENCE.

Check his times in between refills...count the pills in his bottle to see if he's been taking them as directed (but don't make assumptions because some people re-use bottles) Then you can move on to open ended questions. How do you take it? When do you take it?

Also, when was his BP read compared to when he took his last anti-hypertensive? He could very well be controlled but never took his med that day or he took it in the early AM and you read it in the afternoon. Did you take more han one BP over 5 minutes to try and rule out whitecoat syndrome?

What's the family history? Any history of stroke, MI, DM? How is the pt's renal function? What are his K levels? When was his last fasting lipid panel? Just because a dose seems "wussy" doesn't mean it is necessary.

Student: Uhhh....yeah...Professor Smith...can we increase his simvastatin...it seems a little wussy

Professor: No Mr. Shmuckatelly, you cannot...this is not PA school!



You need to try and answer all these things before considering increasing or adding meds.

There are enough soap boxes here to start a laundry mat!

If the patient has been on Lisinopril and HCTZ for at least 4 wks but his BP is still high, then increase HCTZ 25mg to 50mg qam. However, check his potassium level first before you decide to increase his HCTZ. If after 4 wks, his BP is still high then increase lisinopril. No need to add another drug at this point.

The increase from 25 to 50 on the HCTZ isn't likely to provide much extra BP effect and you'll just increase the risk of side effects. I'd up the lisinopril and if that isn't enough then consider a beta blocker.

See the article titled "Response of isolated systolic hypertension to various doses of hydrochlorothiazide: results of a Department of Veterans Affairs cooperative study. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents." for a study comparing 25 to 50mg HCTZ. PMID 1929683

boring...

stevephhs016 said:

Did the patient try lasix or a HCTZ? That could be a first option.

The patient can also go with a nitrate/hydralazine combination such as bidil. Those have proven efficacy with african americans.

Also, if the swelling was found to be due to amlodipine, that shouldn't be a problem to withdraw the drug.

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Never heard of lasix as a 1st option for bp. It will help relieve edema, but not great for bp.

VCU07 said:

Never heard of lasix as a 1st option for bp. It will help relieve edema, but not great for bp.

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Except if CrCl was ~15 ml/min, but of course we don't know that.

I was taught: (if no compelling indications)
-"thiazide diuretics for most"
-then choose: ACEI, ARB, BB, CCB, clonidine, vasodilators, etc

Since the patient is still hypertensive, and if Scr and K is okay, raising the dose may help, or you could add another drug. What's the pt. pulse? History...SH, FH....financial situation?

Based on what you have mentioned, pt. age, I would say try to increase the dose first, then try other drugs. But that's just my opinion. And those are like butts.

upping HCTZ 25mg BID might be good too scheduled at 7am and 2pm, and make sure he can actually afford the drugs and actually taking it in the first place. Also know what he do/job and his stresses in life.

There is data to support switching the HCTZ to chorthalidone or simply adding a diuretic. Recent guidelines on resistant hypertension (not sure your patient necessarily qualifies) indicate that diuretics are often underappreciated, and a group of PharmD's from Iowa have demonstrated that chlorthalidone offered better control than HCTZ.

Priapism321 said:

a group of PharmD's from Iowa showed that chlorthalidone offered better control than HCTZ.

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Chlorthalidone is 1.5-2.5x the potency of HCTZ and has longer duration than HCTZ so not too surprised.

"The increase from 25 to 50 on the HCTZ isn't likely to provide much extra BP effect and you'll just increase the risk of side effects. I'd up the lisinopril and if that isn't enough then consider a beta blocker."


I agree. Check all his other ****, too--history, labs, organ function, etc.