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Clinical Focus: How can I maximize blood pressure control for my patients and also minimize pill burden?
A 53 M presents for follow-up of his hypertension. He has a history which includes:
- CAD – NSTEMI 2 years ago with PCI
- DM II – A1C is 7.6% and the patient has documented retinopathy
- Dyslipidemia with an LDL of 1.8 (Treated)
- CKD with a GFR of 62 and an ACR of 12.85 mg/mmol.
His current medications include:
- Losartan 100mg Daily
- Amlodipine 10mg Daily
- HCTZ 25mg Daily
- Metoprolol 50mg BID
- Lipitor 40mg Daily
- ASA 81mg Daily
On examination, the patient’s BMI is 35. Two years ago, his BMI was 40. His BP in clinic 151/98 (average after five measurements on a BPTru). The remainder of his exam reveals an S4 as well as mild edema. JVP is estimated to be 4cm. You patient did bring home monitoring and confirms his average home BP is 145/91. You clinic pharmacist has reviewed the patient for compliance and he is assessed as being very compliant.
Pertinent labs are as follows:
- Creat 115; GFR 62; ACR 12.8
- Electrolytes are normal with K of 3.8
- LDL 1.8
- A1C 7.6%
What is the definition of resistant hypertension? (click one)
2. What is this patient’s BP target? (click one)
3. What are the major causes of resistant hypertension? (click one)
Back to the Case
After assessing the patient, you decide to add spironolactone to the patient’s regimen. He refuses to add another medication to his mixture as he is already taking to many pills and is worried about side effects. After doing some research and speaking with a colleague, you decide to try and maximize his regimen. In order to do this, you prioritize goals in your mind.
Please take a moment to write down some goals or objectives.
Possible goals of importance include:
- Maximization of ARB given the strong data for renal protection
- Conversion of medications to longer acting drugs to maximize cardiac protection
- Conversion of the patient to a longer acting thiazide in order to be inline with Hypertension Canada 2017 guidelines. Additionally, this may provide better BP control and better CV outcomes.
- Implementation of combination therapy to minimize the complexity of the regimen
Referral to a specialist to help in the work-up of this patient and to rule out secondary causes of hypertension.
Given your goals and those of the patient, you elect to put the patient on Edarbyclor (Azilsartan and chlorthalidone) 40/25mg daily. Azilsartan is the most potent ARB and is also a 24 hour medication. When compared head to head with other ARBs, patients can expect significant BP reductions. Additionally, the 24 hour mode of action ensures optimal BP control. Chlorthalidone is a much more potent diuretic than HCTZ in terms of BP control and CV outcomes. You also remind the patient that ARBS and diuretics are SADMANS medications. After implementing this maneuver, the patient’s BP drops to 134/83. Follow-up blood work 7 days later reveals stability of GFR. Additionally, you refer the patient to a Nephrologist. After 3 months, the Nephrology assessment reveals that the patient has unilateral renal artery stenosis. The Nephrologist elects to watch this issue, but recommends that the patient be assessed for OSA. At 6 month review, the patient is treated with CPAP after being diagnosed with OSA and now has a mean BP of 127/78.
Monthly Clinical Pearl
Compliance and adherence can be improved with combination therapy. Selection of medications that are long-acting can reduce medication regimen complexity. Selection of medications that are more potent can also reduce medication complexity. Resistant hypertension is often multi-factorial and may require referral to a specialist for further assessment.