Management of Uncontrolled Hypertension with Thiazide/Thiazide-like Diuretics

Rationale for Adding a Thiazide/Thiazide-like Diuretic

The International Society of Hypertension (ISH) recommends adding a thiazide/thiazide-like diuretic as the next step in therapy for patients on maximum dose dihydropyridine calcium channel blocker (DHP-CCB) who have not achieved target blood pressure 1, 2
The American Heart Association (AHA) supports a stepwise approach for hypertension management, including the addition of a thiazide/thiazide-like diuretic for patients who have not achieved target blood pressure on monotherapy 3

For non-black patients, the treatment algorithm includes starting with low dose ACEI/ARB, increasing to full dose, adding a thiazide/thiazide-like diuretic, and then adding spironolactone or alternatives if not tolerated 4, 5
For black patients, the treatment algorithm includes starting with low dose ARB + DHP-CCB or DHP-CCB + thiazide/thiazide-like diuretic, increasing to full dose, adding a diuretic or ARB/ACEI, and then adding spironolactone or alternatives if not tolerated 4, 5

The target blood pressure should be <130/80 mmHg according to current guidelines 6
Adding a thiazide/thiazide-like diuretic provides a complementary mechanism of action to the calcium channel blocker 2, 3

Blood pressure should be monitored to achieve target within 3 months 1
Target reduction should be at least 20/10 mmHg with an ideal goal of <130/80 mmHg 2, 6

If blood pressure remains uncontrolled after adding a thiazide/thiazide-like diuretic, the next step would be to add spironolactone (if tolerated) or alternatives like amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 4, 1
If blood pressure remains uncontrolled despite optimal medical therapy, refer to a provider with expertise in hypertension management 6
Always assess for potential secondary causes of hypertension, particularly in younger patients with resistant hypertension 2

The patient's current blood pressure of 106/90 mmHg indicates uncontrolled diastolic hypertension despite treatment with azilsartan (EDARBI) 40mg daily, according to the International Society of Hypertension guidelines 7

The International Society of Hypertension guidelines recommend increasing azilsartan from 40mg to 80mg daily and monitoring blood pressure response for 2-4 weeks after dose adjustment, with a target blood pressure of <130/80 mmHg 7
If blood pressure remains uncontrolled, the International Society of Hypertension guidelines recommend adding a thiazide/thiazide-like diuretic, such as chlorthalidone, to achieve target blood pressure 7
The European Society of Cardiology recommends considering a fixed-dose combination of azilsartan/chlorthalidone for improved adherence if both medications are required 8

The European Society of Cardiology recommends a target blood pressure of <130/80 mmHg, with an aim to reduce blood pressure by at least 20/10 mmHg from baseline 8
The International Society of Hypertension guidelines recommend aiming to reduce blood pressure by at least 20/10 mmHg from baseline and achieving blood pressure control within 3 months 7

The International Society of Hypertension guidelines recommend following up within 2-4 weeks after medication changes to assess efficacy and tolerability 7

The European Society of Cardiology recommends avoiding combining azilsartan with other renin-angiotensin system blockers, such as ACE inhibitors, as this combination is not recommended 8
The International Society of Hypertension guidelines recommend considering adding spironolactone as the next agent if blood pressure remains uncontrolled on maximum dose azilsartan plus a thiazide diuretic 7