An 87-year-old man with a history of hypertension and gonarthrosis. Baseline situation with full functional and cognitive autonomy that allows him to continue living alone in the community. He is receiving regular treatment with perindopril and thiazide diuretic for blood pressure control and routinely takes ibuprofen 1800 mg/day to control the symptoms derived from his gonarthrosis. After routine control, a persistent blood pressure of 190 and TAD 80 mmHg was observed. What would be the most reasonable therapeutic modification to achieve blood pressure control?
One of the mechanisms that produce the hypotensive effect of ACE inhibitors such as perindopril is the increased action of vasodilator prostaglan-dins on the kidney, which decreases hydrosaline retention and therefore increases diuresis and lowers blood pressure. NSAIDs inhibit prostaglandin synthesis and decrease renal perfusion, thus antagonizing the hypotensive effect of many antihypertensives, including ACE inhibitors. Therefore, the preferable thing to do in this patient, before increasing the medication, is to change the ibuprofen for paracetamol, which does not have this effect, and to re-evaluate it later.
I would add a calcium channel blocker.
I would increase the dose of hydrochlorothiazide to 25 mg/day.
I would change ibuprofen to paracetamol to avoid the possible influence of paracetamol on the effect of hypotensives.
I would add an alpha-blocker because of the high prevalence of prostatic syndrome in males of this age.
NSAIDs inhibit prostaglandin synthesis and decrease renal perfusion, thus antagonizing the hypotensive effect of many antihypertensives, including ACE inhibitors. Therefore, the preferable thing to do in this patient, before increasing the medication, is to change the ibuprofen for paracetamol, which does not have this effect, and to re-evaluate it later.