MT is a 64-year-old female recently diagnosed with hypertension. Her physician is looking for an appropriate drug regimen to initiate.
Past medical history: osteoarthritis, type 2 diabetes, asthma
Current medications:
Acetaminophen 500mg q6h PRN
Metformin 1000 BID
Advair 50/250mcg 1 inhalation BID
Allergies: Sulfa (Stevens Johnson Syndrome)
Labs/Vitals:
Ht: 5’5 ft
Wt: 186 lbs
BP: 146/88 mmHg
HR: 79 BPM
Temp: 98.2 F
Glucose: 128 mg/dL (70-130 mg/dL)
Scr: 1.6 mg/dL (0.5-1.2 mg/dL)
Na: 139 mEq/L (135-145 mEq/L)
Cl: 103 mEq/L (95-105 mEq/L)
K: 4.1 mEq/L (3.5-5 mEq/L)
Ca: 8.4 mg/dL (8.5-10.5 mg/dL)
Mg: 1.4 mg/dL (1.7-2.2 mg/dL)
eGFR: 58 ml/min
Urine albumin-to-creatinine ratio (UACR): 200 mg/g (<30 mg/g)
Which of the following is the most appropriate initial antihypertensive therapy for this patient?
A. Hydrochlorothiazide
B. Amlodipine
C. Lisinopril
D. Carvedilol
Answer with rationale:
The disease states of hypertension and diabetes are often found to coexist and together can increase the risk of cardiovascular morbidity, such as stroke and kidney disease as well as mortality. While 4 major classes of antihypertensives, including thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and nondihydropyridine calcium channel blockers are all first-line antihypertensives, patient specific factors and comorbidities often will help direct to a particular class of therapy.
The key with our patient is their labs which indicate a comorbid condition which would be best suited to one of our listed options. Let's discuss each answer.
Answer A is incorrect: Hydrochlorothiazide is a first line agent for hypertension but would not be preferred with our patient's documented albuminuria. Thiazide diuretics such as hydrochlorothiazide can create insulin resistance and elevate blood glucose levels but still can be used in diabetes patients with monitoring. The chemical structure of hydrochlorothiazide contains a sulfonamide group which in patients with mild reactions to sulfa drugs can often still be used. However, hydrochlorothiazide as a potential treatment option for our patient would be contraindicated due to the patient possessing a severe sulfonamide allergy of Stevens Johnson Syndrome.
Answer B is incorrect: Similar to hydrochlorothiazide, amlodipine is FDA approved for hypertension but not a first line option in patients with diabetes with albuminuria. Amlodipine does not reduce proteinuria or protect kidney function comparatively to ACE inhibitors or ARBs and in some studies may increase albuminuria.
Answer C is correct: ACE inhibitors such as lisinopril are considered the first line treatment option for patients with hypertension in combination with diabetes. ACE inhibitors have a cardiovascular protective effect and offer renal protection. Renal protection and diabetic benefits provided by ACE inhibitors includes reduction of proteinuria and slowed progression of nephropathy. This is also true for ARBs if patients have intolerance to ACE-I therapy (e.g. cough).
Answer D is incorrect: Beta blockers such as carvedilol are not an ideal initial treatment option for asthma patients with hypertension. Carvedilol is a non-selective beta blocker that can result asthma patients experiencing further bronchoconstriction due to nonselective blocking of the beta receptor in the lungs. Beta blockers may also mask hypoglycemia in this patient with the exception of sweating. Beta blockers however are a preferred first line option for patients suffering from chronic heart failure or who have recently experienced a myocardial infarction.
Brand/generics Covered:
Metformin (Glucophage), Acetaminophen (Tylenol), fluticasone/salmeterol (Advair), Hydrochlorothiazide (Microzide), Amlodipine (Norvasc), Lisinopril (Zestril), Carvedilol (Coreg)
Naplex Content Domains Covered:
- C. 1 – Signs, symptoms, and findings of medical conditions, etiology of diseases, or pathophysiology
- C. 2 - Appropriateness of therapy