Magazine article Drug Topics

Hypertension: Upping the Ante

Magazine article Drug Topics

Hypertension: Upping the Ante

Article excerpt

A new medical resident calh your hospital pharmacy to ask the maximum dose of losartan (Cozaar, Merck). His patient, a 51-year-old African-American man (BMI=23), has an average blood pressure of 150/90 despite total daily doses of 10 mg amlodipine; 25 mg atenolol; 80 mg furosemide; 40 mg lisinopril; and 100 mg losartan. When you access the patient's profile, you discover he aho iakes potassium 10 mEq/day, ranitidine 150 mg twice daily, simvastatin 40 mglday, and insulin 70/30. His diabetes appears well controlled, but he has had nocturnal dyspnea previously that was attributed to heart failure (HF). He has no current HF symptoms. What do you suggest?

Prior to providing recommendations, review the patient's medical record for cardiac evaluation (ejection fraction, NYHA classification), kidney function (CrCl, SCr), potassium levels, and so on. Review his medication reconciliation record for nonprescription drugs, herbal/dietary supplements, and medications from multiple physicians.

Currently, the patient appears asymptomatic for HF and his diabetes is controlled; however, he remains hypertensive (> 130/80).

Consider optimization of all medications for HF and hypertension (HTN) instead of increasing losartan, i.e., angiotensin-receptor blocker (ARB) dosing.

HF pharmacotherapy targets neurohormonal blockade with ACE inhibitors (ACEIs), beta-blockers, aldosterone blockers, and digoxin. These medications (except digoxin) have demonstrated a reduction in mortality and hospitalization; digoxin reduces HF symptoms. Medications from these classes (excluding digoxin) also contribute to the management of HTN.

Unless hyperkalemia and/or impaired kidney function are present, medications should be administered at recommended target doses. Because this patients treatment includes an ACEI/ARB combination as well as a potassium supplement, serum potassium should be assessed.

Continue lisinopril (ACEI) as currently titrated to recommended maximum dose and consider substituting isosorbide dinitrate/hydralazine (BiDiI, NitroMed) for losartan (A-HeFT Trial) that, via its vasodilatory nitric-oxide-dependent endothelial mechanism, is effective in the African-American population.

Consider metoprolol succinate, Carvedilol (Coreg, GlaxoSmithKline), or bisoprolol titrated to the respective daily target doses of 200 mg, 25-50 mg, and 10 mg, in lieu of atenolol for beta-blockade.

Since aldosterone blockers are recommended in HF, treatment with spironolactone 25 mg or eplerenone (Inspra, Pfizer) 25 mg daily should be considered. …

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