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What Causes Resistant Hypertension?
Question: hello sir...i passed my mbbs two years back n m preparing for my pg....my grandfather has been hypertensive for past many years...he was recently prescribed clinidipine 20mg and telmisartan 80mg both one tab once daily...but as his b.p remained around 180/80 even after taking these medications lasilactone 50 mg was added....now these three are causing a brisk fall in pressure daily to round about 150/70 but the effect doesnt last for the entire day and it rises steeply to about 180/90 or so before the next dose is taken....his coronaries are clear on angiography....ecg showed stress induced ischemia.....his blood levels are as follows ca-8.5,uric acid 6.7,urea-32,creatinin-1.1,k-5,cl-100,fbs-99,ppbs-119,na-143......his legs are also a bit swollen though from what i know clinidipine doesnt cause pedal edema.....his heart rate is always normal ranging from 72 to 80...recently he had an episode of near fainting....kindly suggest some medication with the appropriate dosage....we stay in a remote place where cardiologists are not available...please help sir...he is 81yrs old with normal lipid levels
Brief Answer:
please see details below
Detailed Answer:
Dear Sir
Resistant hypertension has multiple causes, which can be related to life style and medicines. These include
Excessive sodium intake
Volume retention from kidney disease
Inadequate diuretic therapy
Obesity
Excess alcohol intake
Inappropriate combination
Secondary hypertension
Non-adherence
Inadequate doses
Drugs like NSAIDs, erythropoetin, steroids, decongestants, anorectics, OCPs, cyclosporin
Since you are a medico yourself, I would like you to look into all these factors diligently. I sincerely hope that you will get answer in any of these.
However In our practice, When we do not find any tangible reason for resistance , we add more drugs, these may include central alpha2 receptor agonists (e.g. clonidine, moxonidine), Alpha adrenergic blockers (e.g. prazosin), beta-blockers etc. At times higher doses of aldosterone antagonists work well. However all these medications have their own side effects and precautions. Before you get a fresh prescription for any of them I would like to tell you that all first line drugs take about 2-3 weeks to show their full anti-hypertensive effect. Hence, we normally wait to see their full effect, unless it is an emergency. Second, how and when you measure BP is equally important. You must not measure BP at least for one hour after tea, meals, coffee, exertion or exercise. You must not measure it when patient has acute physical or mental stress like headache or a domestic feud.
Hope this helps. Feel free to discuss further.
Sincerely
Sukhvinder
please see details below
Detailed Answer:
Dear Sir
Resistant hypertension has multiple causes, which can be related to life style and medicines. These include
Excessive sodium intake
Volume retention from kidney disease
Inadequate diuretic therapy
Obesity
Excess alcohol intake
Inappropriate combination
Secondary hypertension
Non-adherence
Inadequate doses
Drugs like NSAIDs, erythropoetin, steroids, decongestants, anorectics, OCPs, cyclosporin
Since you are a medico yourself, I would like you to look into all these factors diligently. I sincerely hope that you will get answer in any of these.
However In our practice, When we do not find any tangible reason for resistance , we add more drugs, these may include central alpha2 receptor agonists (e.g. clonidine, moxonidine), Alpha adrenergic blockers (e.g. prazosin), beta-blockers etc. At times higher doses of aldosterone antagonists work well. However all these medications have their own side effects and precautions. Before you get a fresh prescription for any of them I would like to tell you that all first line drugs take about 2-3 weeks to show their full anti-hypertensive effect. Hence, we normally wait to see their full effect, unless it is an emergency. Second, how and when you measure BP is equally important. You must not measure BP at least for one hour after tea, meals, coffee, exertion or exercise. You must not measure it when patient has acute physical or mental stress like headache or a domestic feud.
Hope this helps. Feel free to discuss further.
Sincerely
Sukhvinder
Above answer was peer-reviewed by :
Dr. Veerisetty Shyamkumar
sir what would be better for him....increasing the dose of clinidipine or adding prazosin to the medications already going on...can hydrochlorothiazide be given at his age or should we go for a beta blocker....please tell us what would your choice be????his calcium level at present is 8.5
Brief Answer:
please see details
Detailed Answer:
Dear Sir
1. Dose of cilnidipine can not be increased further. Moreover, Cilnidipine may cause pedal edema.
2. Adding HCTZ over lasilactone is not recommended.
3. I usually look for all the factors responsible for resistant hypertension first. There after I add any other drug. Depending upon the profile of patient it may be clonidine/moxininidne or a beta-blocker. Its prudent to get him examined from a cardiologist/ physician before adding another drug.
Sincerely
Sukhvinder
please see details
Detailed Answer:
Dear Sir
1. Dose of cilnidipine can not be increased further. Moreover, Cilnidipine may cause pedal edema.
2. Adding HCTZ over lasilactone is not recommended.
3. I usually look for all the factors responsible for resistant hypertension first. There after I add any other drug. Depending upon the profile of patient it may be clonidine/moxininidne or a beta-blocker. Its prudent to get him examined from a cardiologist/ physician before adding another drug.
Sincerely
Sukhvinder
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Priyanka G Raj
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