Next best treatment for htn pt?

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monkeypharmd

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Hi everyone! Wondering if I could get some opinions on the next best treatment for this patient.
I have a 63 yo male patient that has been getting bp readings of 160-170s/90s. He exercises regularly, watches salt intake however he smokes 5 cigs/day. He has made it clear he does NOT want to quit. Otherwise he has no major disease states.
His meds are:
lasix 80 mg daily
Potassium (forgot the dosage)
Metoprolol tartrate 100mg bid
Minoxidil 10mg bid
Lisinopril 40mg daily
Amlodipine 10mg daily
Omeprazole 40mg daily

His new pcp has asked if they are other things pt may try to get his bp down. I'm thinking of discontinuing his lasix/potassium and starting chlorthalidone. Not sure what to do if that doesn't work. Any other suggestions?
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monkeypharmd said:
Hi everyone! Wondering if I could get some opinions on the next best treatment for this patient.
I have a 63 yo male patient that has been getting bp readings of 160-170s/90s. He exercises regularly, watches salt intake however he smokes 5 cigs/day. He has made it clear he does NOT want to quit. Otherwise he has no major disease states.
His meds are:
lasix 80 mg daily
Potassium (forgot the dosage)
Metoprolol tartrate 100mg bid
Minoxidil 10mg bid
Lisinopril 40mg daily
Amlodipine 10mg daily
Omeprazole 40mg daily

His new pcp has asked if they are other things pt may try to get his bp down. I'm thinking of discontinuing his lasix/potassium and starting chlorthalidone. Not sure what to do if that doesn't work. Any other suggestions?
Click to expand...

In therapy we would want to know the patient's resting heart rate to determine if patient is fully beta-blocked. At that dose I would expect him to be. Maybe cut down on caffeine or have patient take BP at home?

EDIT: You specifically wanted therapy, I see that now. Sorry.
 
monkeypharmd said:
Hi everyone! Wondering if I could get some opinions on the next best treatment for this patient.
I have a 63 yo male patient that has been getting bp readings of 160-170s/90s. He exercises regularly, watches salt intake however he smokes 5 cigs/day. He has made it clear he does NOT want to quit. Otherwise he has no major disease states.
His meds are:
lasix 80 mg daily
Potassium (forgot the dosage)
Metoprolol tartrate 100mg bid
Minoxidil 10mg bid
Lisinopril 40mg daily
Amlodipine 10mg daily
Omeprazole 40mg daily

His new pcp has asked if they are other things pt may try to get his bp down. I'm thinking of discontinuing his lasix/potassium and starting chlorthalidone. Not sure what to do if that doesn't work. Any other suggestions?
Click to expand...

Not the place for homework help...but there's probably a very obvious answer. Also: Minoxidil? Seriously?
 
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This is not a homework and this is a real patient. I was surprise he was on minoxidil too but he has been on it for several years by his old pcp. The averages I listed are his home bp readings. His pulse is 70-80s.
 
Praziquantel86 said:
Not the place for homework help...but there's probably a very obvious answer. Also: Minoxidil? Seriously?
Click to expand...

saw minoxidil used a couple of times during my amb care rotation, usually after all the standards and hydralazine werent enough.

I dont think lasix is the right diuretic for this pt unless theres a HF diagnosis, I'll say that
 
monkeypharmd said:
This is not a homework and this is a real patient. I was surprise he was on minoxidil too but he has been on it for several years by his old pcp. The averages I listed are his home bp readings. His pulse is 70-80s.
Click to expand...

Then there is room for more beta-blocking. I have to wonder about complaince though - that is quite a bit of lifestyle modification and medication to be ineffective. What was his BP before medication I wonder.
 
monkeypharmd said:
This is not a homework and this is a real patient. I was surprise he was on minoxidil too but he has been on it for several years by his old pcp. The averages I listed are his home bp readings. His pulse is 70-80s.
Click to expand...

Well then, in that case, there are a few additional questions that need to be answered:

1) Is he compliant with his medications? - potentially the main issue
2) Has he been worked up for secondary causes of hypertension?
3) What are is comorbid conditions?

Discontinuing the Lasix with concomitant minoxidil is a big no-no. If he is in fact compliant with his medications with no additional comorbidities, there are a few ways you could approach this. You could attempt to switch the metoprolol to labetalol, which is better at controlling the blood pressure (although orthostasis is a concern with minoxidil). The other possibility, probably what I'd attempt first, is switching the minoxidil to something like hydralazine.

You could also add a thiazide, however, my main concern would be removing the minoxidil. There's a reason why it isn't used very frequently. Given appropriate titration, you should see a response to the hydralazine.
 
What is the issue with lasix and minoxidil? Your right about compliance being a concern but he swears he is compliant. Reviewing his refill history there is a gap however he has been at least taking meds consistently for 3 months.
 
monkeypharmd said:
What is the issue with lasix and minoxidil? Your right about compliance being a concern but he swears he is compliant. Reviewing his refill history there is a gap however he has been at least taking meds consistently for 3 months.
Click to expand...

The furosemide helps prevent the development of edema from minoxidil. I think.
 
monkeypharmd said:
What is the issue with lasix and minoxidil? Your right about compliance being a concern but he swears he is compliant. Reviewing his refill history there is a gap however he has been at least taking meds consistently for 3 months.
Click to expand...

Fluid retention leading to pericardial effusion. It has 3 black box warnings related to this.
 
The furosemide(80-120mg) is for the minoxidil due to massive edema associated with minoxidil treatment, otherwise mainly used with HF diagnosis. Also I was taught that minoxidil should only be used in cases of severe resistant HT, not for regular treatment.

Does the patient suffer from sleep apnea or is he not a dipper(high bp during sleep)? Caucasian or African American? When is he taking his readings? Morning, night, both? What's his CrCl? The ACEI + potassium could create a hyperkalemia issue if he has any sorts of renal impairment too...I know it's a bit off topic but just an observation/concern and something to keep in mind.

I think you are on the right track with the switch to a thiazide. From there I'd have to think it over a little bit and gather more info.
 
monkeypharmd said:
Hi everyone! Wondering if I could get some opinions on the next best treatment for this patient.
I have a 63 yo male patient that has been getting bp readings of 160-170s/90s. He exercises regularly, watches salt intake however he smokes 5 cigs/day. He has made it clear he does NOT want to quit. Otherwise he has no major disease states.
His meds are:
lasix 80 mg daily
Potassium (forgot the dosage)
Metoprolol tartrate 100mg bid
Minoxidil 10mg bid
Lisinopril 40mg daily
Amlodipine 10mg daily
Omeprazole 40mg daily

His new pcp has asked if they are other things pt may try to get his bp down. I'm thinking of discontinuing his lasix/potassium and starting chlorthalidone. Not sure what to do if that doesn't work. Any other suggestions?
Click to expand...

Obvious stuff: hctz or chlorthalidone

Other options: hydralazine; alpha blocker or alpha 2 agonist. Choose based on pt hx: alpha blocker with BPH or PTSD; clonidine if maybe ADHD. otherwise, I would go hydralazine after the thiazide switch.

less obvious stuff: add an ARB (and maybe tekturna after that). With chronic use of ACEI, body upregulate renin to compensate. Double blockade of RAAS will still produce a notable effect (my experience is another 10 mmHg). Even triple blockade will still produce another noticeable drop. This will off set even more of the potassium loss from the lasix. But make sure you keep an eye on the SrCr. I would stop adding more RAAS blocker when SrCr is up by 0.5 from baseline.

minoxidil should be something of a last resort, along with stuff like reserpine. Although if the guy wanted to grow some hair badly enough... ;)
 
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TonyRx said:
The furosemide(80-120mg) is for the minoxidil due to massive edema associated with minoxidil treatment, otherwise mainly used with HF diagnosis. Also I was taught that minoxidil should only be used in cases of severe resistant HT, not for regular treatment.

Does the patient suffer from sleep apnea or is he not a dipper(high bp during sleep)? Caucasian or African American? When is he taking his readings? Morning, night, both? What's his CrCl? The ACEI + potassium could create a hyperkalemia issue if he has any sorts of renal impairment too...I know it's a bit off topic but just an observation/concern and something to keep in mind.

I think you are on the right track with the switch to a thiazide. From there I'd have to think it over a little bit and gather more info.
Click to expand...

Furosemide and a thiazide? That is quite a potent combination. Throw in increased risk of falls in the elderly and the fact HCTZ is not so great for HTN, guidelines notwithstanding...I am not saying it's a bad idea, but I personally don't think the pros outweigh the cons. Optimize that beta-blocker I say!

It's possible that the resting heart rate is giving you a clue about complainance, just saying...
 
Agree with many have stated; compliance and lifestyle are the biggest factors. The fact he smokes and does NOT want to quit is pretty big, not to mention he is likely lying about ONLY 5 cigs/day. If he has a history of non-compliance and consistent high bp then he is likely on his way of developing resistant HT...if not already there.


I didn't mean both diuretics, worded that poorly...my bad. I meant just thiazide. But, like many have said, the minoxidil treatment is a bit tricky and sketchy...so the loop has to stay if the minoxidil stays.
 
owlegrad said:
Furosemide and a thiazide? That is quite a potent combination. Throw in increased risk of falls in the elderly and the fact HCTZ is not so great for HTN, guidelines notwithstanding...I am not saying it's a bad idea, but I personally don't think the pros outweigh the cons. Optimize that beta-blocker I say!

It's possible that the resting heart rate is giving you a clue about complainance, just saying...
Click to expand...

nothing wrong with the combo per se. Good for taking off a lot of fluid (Metolazone + lasix combo is use frequently for synergistic diuresis in CHF and renal failure patients), but not sure how much more BP it will help to lower than a single agent.

Also note: "BP 160-170s/90s". Don't know if the pt is diabetic or not, but even if he's not, adding another agent is not likely to get it to goal of SBP <140. So he'll likely need the thiazide switch and then another new agent added.
 
TonyRx said:
Agree with many have stated; compliance and lifestyle are the biggest factors. The fact he smokes and does NOT want to quit is pretty big, not to mention he is likely lying about ONLY 5 cigs/day. If he has a history of non-compliance and consistent high bp then he is likely on his way of developing resistant HT...if not already there.


I didn't mean both diuretics, worded that poorly...my bad. I meant just thiazide. But, like many have said, the minoxidil treatment is a bit tricky and sketchy...so the loop has to stay if the minoxidil stays.
Click to expand...

I kinda went back and forth about that. If we d/c minoxidil+furosemide and replace with HCTZ, I wouldn't expect his BP to improve, in fact I would expect him to get worse.

I like what someone upstream mentioned about doing a workup for possible causes of his hypertension. That would be an excellent place to start. Is the patient overweight? I don't see anything for lipids or diabetes so just curious how much of a contribution his weight could be having.
 
Thanks for all the helpful advise! To answer your question, he is not diabetic or chf and from my memory he is not overweight. All his lytes and renal function are wnl and no swelling.
 
Regarding the increasing Beta Blocker route, my only input is that "in general" BB's are less effective in elderly hypertensives. Which is most likely is due to decreased levels of renin in elderly (african americans too), which is a major role of beta-1 suppression of the BB's.

I know you will need a BB in treatment for sure, especially to counter reflex increases in HR, renin, AII, etc from the diuretic...but not entirely sure if focusing on the BB for better BP lowering is beneficial.

I completely agree that more info is needed regarding weight, DM, renal, etc, etc. This info is critical in getting to the root of the problem.
 
monkeypharmd said:
Thanks for all the helpful advise! To answer your question, he is not diabetic or chf and from my memory he is not overweight. All his lytes and renal function are wnl and no swelling.
Click to expand...


whoops, just saw you posted this...
 
Amlodipine (or any DHP CCB for that matter) cause edema as a common SE as well, which may also be the reason for lasix.
 
ronkoshy said:
have him stop smoking.

or let him get a stroke, mi, or go blind. then when he decides to finally stop smoking after one of those happens his bp will go down.

seriously, hes on almost everything. ask him what he thinks will happen if he continues to smoke, then ask him what he thinks will happen if he stops smoking. develop some discrepancy in which he will realize he has to make a change.
Click to expand...

you realize that you can't make a horse drink. Give them the info, your advice, but you'll have to leave the treatment choice to them.

Pts have the right to refuse, and the right to be stupid. :D
 
ronkoshy said:
have him stop smoking.

or let him get a stroke, mi, or go blind. then when he decides to finally stop smoking after one of those happens his bp will go down.

seriously, hes on almost everything. ask him what he thinks will happen if he continues to smoke, then ask him what he thinks will happen if he stops smoking. develop some discrepancy in which he will realize he has to make a change.
Click to expand...


Generate a gap!
 
TonyRx said:
Regarding the increasing Beta Blocker route, my only input is that "in general" BB's are less effective in elderly hypertensives. Which is most likely is due to decreased levels of renin in elderly (african americans too), which is a major role of beta-1 suppression of the BB's.
Click to expand...

I am not disagreeing, you know your stuff.



BUT :laugh: it is always better to optimise current therapy before adding new meds, right? His lopressor is not optimized, so I would want to address that. The thread consensus seems to be that it's up to the patient at this point though (smoking, being complaint).
 
owlegrad said:
I am not disagreeing, you know your stuff.



BUT :laugh: it is always better to optimise current therapy before adding new meds, right? His lopressor is not optimized, so I would want to address that. The thread consensus seems to be that it's up to the patient at this point though (smoking, being complaint).
Click to expand...

Yea you have a valid point for sure, given he's on 100mg/daily and I believe max dose is around 350-450...there's room for optimization. :thumbup:
 
TonyRx said:
Yea you have a valid point for sure, given he's on 100mg/daily and I believe max dose is around 350-450...there's room for optimization. :thumbup:
Click to expand...

Published max dose is indeed 450/day, but once heart rate is 60 BPM or so (I think? I am going by memory here so don't take my word for it) you are fully beta-blocked and there is no benefit to increasing dose. I have never seen doses anywhere near 450/day for whatever that is worth (not much :laugh:). Like I mentioned before, I think his HR shows us he is not really on his meds, but that is just my inner cynic coming out.
 
owlegrad said:
Published max dose is indeed 450/day, but once heart rate is 60 BPM or so (I think? I am going by memory here so don't take my word for it) you are fully beta-blocked and there is no benefit to increasing dose. I have never seen doses anywhere near 450/day for whatever that is worth (not much :laugh:). Like I mentioned before, I think his HR shows us he is not really on his meds, but that is just my inner cynic coming out.
Click to expand...

I see your point and agree. I can see how ~60 BPM would be "fully beta blocked". Not entirely positive either but given BB suppress CO, HR and Contractility...I think it's a good suggestion that you don't wanna go lower than 60.
 
monkeypharmd said:
Hi everyone! Wondering if I could get some opinions on the next best treatment for this patient.
I have a 63 yo male patient that has been getting bp readings of 160-170s/90s. He exercises regularly, watches salt intake however he smokes 5 cigs/day. He has made it clear he does NOT want to quit. Otherwise he has no major disease states.
His meds are:
lasix 80 mg daily
Potassium (forgot the dosage)
Metoprolol tartrate 100mg bid
Minoxidil 10mg bid
Lisinopril 40mg daily
Amlodipine 10mg daily
Omeprazole 40mg daily

His new pcp has asked if they are other things pt may try to get his bp down. I'm thinking of discontinuing his lasix/potassium and starting chlorthalidone. Not sure what to do if that doesn't work. Any other suggestions?
Click to expand...

I would question compliance as well. You didn't mention weight? However if that is ruled out I think this guy gets a 1 way ticket for a cardio referral. I would look for other medical causes for resistant hypertension. i.e. Chronic kidney dz, pheochromocytoma, primary aldosternonism, hyperparathyroid dz etc.
 
We need to know patient's full medical history before making any change. Is he African America? Caucasian? How long have you been on these medications? He may be refractory to the medications. At this moment based on limited information, I would just titrate the dose up for ACEI or BB or CCB. Also, reevaluate fluid status, electrolytes balance.
 
In addition to above post, there is one possibility that his high BP may due to genetic component. Some people have higher BP than others and they are still fine. One thing physician can do is to check his organs status first.
 
Metoprolol succinate, not tartrate. 100mg or 200mg qd.
You can add a thiazide, but it can't replace a loop. Thiazides aren't very good for fluid. More like vascular tone.
 
Agree that he needs a work up for other causes. Maybe spirono, clonidine, or reserpine. Would get rid of the minoxidil for sure.
 
PharmDstudent said:
Metoprolol succinate, not tartrate. 100mg or 200mg qd.
You can add a thiazide, but it can't replace a loop. Thiazides aren't very good for fluid. More like vascular tone.
Click to expand...

I don't think tartrate vs succinate matters much for BP, only for HF (which he doesn't have).
 
PharmD RPh said:
Agree. I've had more patients get better around the clock control with xl dozing and better compliance vs bid dosing.
Click to expand...

Definitely agree with the compliance issue. But just finished cardiology and was taught that the peaks/troughs issue was less critical with BP. It's very important in systolic HF, which is why only the succinate is indicated for that. At the VA, physicians are not permitted to write for the succinate for BP. The patient must have a diagnosis of heart failure with decreased EF.

Whether it would be helpful in this patient, I'm not sure. I think we need more info about him.
 
I've become a big fan of clonidine this year.
 
All4MyDaughter said:
Definitely agree with the compliance issue. But just finished cardiology and was taught that the peaks/troughs issue was less critical with BP. It's very important in systolic HF, which is why only the succinate is indicated for that. At the VA, physicians are not permitted to write for the succinate for BP. The patient must have a diagnosis of heart failure with decreased EF.

Whether it would be helpful in this patient, I'm not sure. I think we need more info about him.
Click to expand...

That must be a formulary/cost issue with the succinate in the VA. I mean I understand why they would do that in that case. Although the COMIT trial showed succinate to be indicated for HF vs tartrate, there were definitely limitations in that study.

I can remember back when we had no generic for Toprol XL. A lot of ins plans gave really high copays or used step therapy making pt try tartrate first. A lot of the pts we switched from XL to immediate release due to cost ended up back on the XL because they had better control. My grandmother was one of these switches and her BP readings were profoundly different between the XL vs immediate release.
 
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