Hypertension Case Study

In this hypertension case study, JD is a 64-year-old male who has a history of hypertension, GERD, gout, diabetes, constipation, and sexual dysfunction and presents with the following medication list.

Hydrochlorothiazide 25 mg daily
Amlodipine 5 mg daily
Omeprazole 20 mg daily
Allopurinol 200 mg daily
Prednisone 40 mg daily for 5 days for gout flare (currently on day 4)
Metformin 1,000 mg BID
Docusate 100 mg daily
Sildenafil 50 mg PRN for sexual dysfunction

His most recent blood pressure was 152/92

In this hypertension case study, I’m most concerned about the hydrochlorothiazide. This medication is well known to contribute to hyperuricemia and may have helped precipitate a gout flare and use of prednisone. In addition, hydrochlorothiazide may also contribute to sexual dysfunction and hyperglycemia. I usually don’t worry a lot about hyperglycemia from a clinical standpoint but I think it is important to highlight that it may contribute to this and would be another reason to consider an alternative.

I have a couple of concerns with the prednisone that should be monitored. Prednisone can significantly raise blood sugar. It can also contribute to hypertension. In the case of treating the gout flare, this is likely a necessary evil that we will have to deal with in the short term. NSAIDs are amazing in this situation but would have less effect on blood sugars than prednisone.

Let’s get back to the main point of this hypertension case study and address hypertension. I’d like to get rid of the hydrochlorothiazide and there are plenty of reasons to change it to an ACE or ARB. Interestingly, losartan has been associated with having a uric acid-lowering effect (definitely something that could show up on your board exam!). Switching the hydrochlorothiazide to losartan would help avoid the adverse effects of hyperuricemia and sexual dysfunction. Using lisinopril or another ARB would also be a reasonable choice.

What other concerns or questions would you have in this hypertension case study?

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