Cardiology

PCP submission

67 year old female with DM (controlled on glizide), CKD 3 (thought to be secondary to DM given albuminuria,) and uncontrolled HTN. Both in the clinic and at home BP ranges from systolic 140s to 170s, diastolic 70s-90s. She is currently taking triamterene/hctz 37/25, spironolactone 25, losartan 100, nifedipine 90, metoprolol succ 200, clonidine 03. bid (she forgets tid). Imaging a couple of years ago did not show renal stenosis. Last GFR 30 and last K 4.7. 

Any suggestions for follow-up on management?

Specialist response

Thank you for the consult. I would recommend switching Metoprolol succinate to Carvedilol 12.5 mg BID. Carvedilol is a nonselective beta blocker so it is more robust than Metoprolol at controlling BP. Carvedilol can be up-titrated to 25 mg BID if she needs additional control. If her BP is still above the goal of 140/90, I recommend adding on Hydralazine 12.5 mg TID (max 100 mg TID). The downside is that this is a TID medication and the frequency is often difficult for patients. I would also consider switching oral Clonidine to Clonidine 0.3 mg patch. Clonidine can cause reflex hypertension with missed doses, so a patch may stabilize her BP a little better. You may want to consider a secondary hypertension workup. It sounds like she was ruled out for renal stenosis previously, but it may be worthwhile to also get a sleep study for OSA, TSH, and renin/aldosterone levels. Thank you again for the consult. Please let me know if there are any additional questions. I hope this was helpful.