How to manage uncontrolled hypertension?

Question

Hello doctor,

I am a healthy 64-year-old male. I have had high blood pressure throughout my entire adult life. I have been taking Tiazac 360 mg, Candesartan 80 mg, and HCTZ 25 mg, and they have been controlling my blood pressure very well. I visited my primary care physician four months ago for my yearly check-up. All of my laboratory results were normal, and my blood pressure was also normal (I do not know the exact reading, but it must have been normal because my doctor did not mention it). I asked him if he could prescribe different blood pressure medications that would be more affordable. He prescribed Losartan 40 mg and told me to get a blood pressure monitor to ensure my BP remained within a normal range. I forgot about the monitor.

After two and a half months, I went to a walk-in clinic for an unrelated issue, and they checked my blood pressure. My systolic reading was around 225. They gave me some Clonidine and brought my BP down to a safe level. The next day, I called my primary care physician and requested to be put back on my original medications, as they had worked well for me all these years. He agreed to restart the medications, but they no longer controlled my blood pressure.

I informed my doctor of my blood pressure readings, and he discontinued Candesartan and prescribed Lisinopril 20 mg once a day, along with Tiazac and HCTZ. However, this did not lower my blood pressure, so he increased the Lisinopril to 40 mg twice a day. This change was made two days ago, but my blood pressure is still not under control.

According to the data from my blood pressure monitor, my average reading in the past two months has been 164/87 mm/Hg, which ranges from 143/87 mm/Hg to 182/92 mm/Hg. My blood pressure is highest in the morning when I wake up. I take Tiazac 360 mg, Lisinopril 40 mg, and HCTZ 25 mg in the morning, and my blood pressure trends down throughout most of the day. However, it starts to rise again in the late afternoon. Do you have any suggestions as to what the problem may be? I am very active and engage in physical activity without experiencing fatigue.

Kindly help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I read your query and understood it.

Hypertension that was previously controlled but has now become uncontrolled likely has many contributing factors. Blood pressure that remains uncontrolled even with three different medications is referred to as resistant hypertension.

I suggest you follow the below-mentioned non-pharmacological measures to help control your resistant hypertension:

Start daily walks and or exercise. Daily walking or exercise has a significant impact on blood pressure control.
Weight reduction. Weight loss has a very significant impact on blood pressure control. Research has shown that for every kilogram of weight loss, there is a two to three mm/Hg reduction in blood pressure.
Reduce salt intake.
Avoid processed, pre-cooked, and preserved foods.
Consider adding salt alternatives to your daily diet to help reduce salt intake.

Regarding your medication, you are almost at the maximum dose for medications such as Tiazac (Diltiazem), Lisinopril, and Hydrochlorothiazide. Therefore, if your blood pressure remains uncontrolled despite the current medications and lifestyle changes, an additional drug must be added to the medications you are already taking.

Adding a medication such as Hydralazine 25 mg twice daily, and then increasing the frequency to three times a day, would be an appropriate start. The Hydralazine dose can be increased up to 100 mg three times a day if needed. Similarly, adding a mineralocorticoid receptor antagonist, such as Spironolactone 25 mg once a day, would also help significantly. The dose can further be increased up to 100 mg a day, divided into two doses.

There are other options as well, but those would be suggested if the above treatments fail to reduce blood pressure. I would also suggest you get the following laboratory tests done before starting any new medication, for screening and risk stratification:

Complete blood count (CBC).
Serum electrolytes.
Serum creatinine.
Thyroid-stimulating hormone (TSH).
Urine dipstick.
A 12-lead electrocardiogram (ECG).

I hope this has helped you.

Kindly follow up if you have more doubts.

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

I read your query and understood your concern.

There are several reasons why medications that previously worked for you might no longer be effective. One possibility is the development of tolerance. This means your body no longer responds to the previous dose of medicine and now requires a higher dose, additional medication, or a different medication altogether. Another reason might be disease progression. For example, if you are treating hypertension, it may have progressed and become resistant, requiring a higher dose or different medication to control it.

Similarly, factors such as aging, recent illness, changes in diet or food, weight gain, weight loss, nutritional supplements, or taking new medications for other conditions can change drug metabolism and, therefore, affect blood pressure control. In most cases, blood pressure gradually becomes controlled, and the physician is able to maintain the patient on the previous dose after some time. Otherwise, a higher dose or an additional medication may be continued.

It is very important to monitor your blood pressure and follow all the pharmacological and non-pharmacological measures as prescribed. I hope this information helps you understand the disease process better.

Kindly follow up if you have more doubts.

Thank you.