A 45-year-old woman comes to the office for hypertension follow-up. She has been taking low-dose amlodipine for the past 2 years, and it has been effective in controlling her blood pressure without adverse effects. The patient has no other medical conditions. In the past year, she initiated and maintained an intensive diet and exercise program, resulting in a weight loss of 15 kg (33 lb). Since then, the patient's blood pressure at home has been consistently 115-120/70-75 mm Hg. Office blood pressure today is 118/74 mm Hg. The patient says "I have worked really hard for the past year to lose weight, and I don't like to take pills. Can I stop taking the blood pressure medication after this visit?" Which of the following is the best response to address the patient's request?

Question

A 45-year-old woman comes to the office for hypertension follow-up.  She has been taking low-dose amlodipine for the past 2 years, and it has been effective in controlling her blood pressure without adverse effects.  The patient has no other medical conditions.  In the past year, she initiated and maintained an intensive diet and exercise program, resulting in a weight loss of 15 kg (33 lb).  Since then, the patient's blood pressure at home has been consistently 115-120/70-75 mm Hg.  Office blood pressure today is 118/74 mm Hg.  The patient says "I have worked really hard for the past year to lose weight, and I don't like to take pills.  Can I stop taking the blood pressure medication after this visit?"  Which of the following is the best response to address the patient's request?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be60_ad33_8f63_8fc1cff95782_MD0005_00 This patient has excellent blood pressure control on a low-dose, single-drug antihypertensive regimen. Since starting the medicine, she has greatly changed her lifestyle, achieving significant weight loss. She therefore may be able to discontinue the medication while maintaining acceptable blood pressure control. To discontinue a long-acting medication, such as amlodipine, the medication can be taken either every other day or in a lower daily dose (eg, half tablet). For short-acting medications (eg, lisinopril), the medication should be taken daily but in a smaller dose (either a half tablet or a smaller prescribed tablet). The blood pressure should be monitored closely over 1-2 months, and if it remains well controlled, the medication can be discontinued and the blood pressure monitored for an additional 1-2 months. If the blood pressure rises above the target, the previous dose of medication should be reinstated. The same approach can be used to eliminate drugs from a multidrug antihypertensive regimen. (Choice A) If blood pressure is under excellent control, lowering the dose or discontinuing blood pressure medications is appropriate even if hypotensive symptoms are absent. (Choice B) If no lifestyle modifications have been made, discontinuation of antihypertensive medication will typically cause blood pressure to rise to pretreatment levels. However, this patient has instituted major lifestyle modifications, and it is unlikely that her blood pressure will return to pretreatment levels. (Choices C and E) Clonidine is a short-acting alpha-2 agonist that is occasionally used for severe hypertensive episodes, not mild hypertension; abrupt discontinuation can lead to severe rebound hypertension. Likewise, discontinuation of short-acting beta blockers, which also are only occasionally used for hypertension, can cause rebound hypertension. However, amlodipine carries little risk of rebound hypertension. Also, all of these medications can be tapered off within a few weeks (eg, 2-3 months), and a longer taper (eg, 6 months) is unnecessary. Educational objective: Patients who have well-controlled hypertension treated with a single drug and have enacted significant lifestyle modifications can often taper and discontinue the medication under close blood pressure monitoring. References: Withdrawal of antihypertensive medication: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/28486271)

A 45-Year-Old Woman Comes to the Office for Hypertension Follow-Up