Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.
A 51-year-old man is evaluated during a follow-up visit for management of newly diagnosed hypertension and diabetes mellitus. He has started a program of lifestyle modification for his diabetes but has not yet started antihypertensive therapy. He is currently taking no medications.
On physical examination, blood pressure is 148/92 mm Hg, and pulse rate is 76/min. BMI is 33. The remainder of the examination is unremarkable.
Laboratory studies show a serum creatinine level of 1.5 mg/dL (132.6 µmol/L) (estimated glomerular filtration rate of 52 mL/min/1.73 m2) and a serum potassium level of 4.2 mEq/L (4.2 mmol/L); a urine dipstick demonstrates no hematuria or proteinuria, and a spot urine protein-creatinine ratio is 50 mg/g.
Which of the following is the most appropriate antihypertensive treatment for this patient?
A. Hydrochlorothiazide
B. Lisinopril
C. Lisinopril and amlodipine
D. Lisinopril and hydrochlorothiazide
E. Lisinopril and losartan
MKSAP Answer and Critique
The correct answer is B. Lisinopril.
The ACE inhibitor lisinopril is appropriate antihypertensive therapy for this patient. He was recently diagnosed with diabetes mellitus and stage 1 hypertension (defined as a systolic blood pressure of 140-159 mm Hg and/or a diastolic blood pressure of 90-99 mm Hg) and is now noted to have chronic kidney disease (CKD). There is evidence that in patients with hypertension and CKD, regardless of diabetes status, renin-angiotensin system agents (ACE inhibitor or angiotensin receptor blocker [ARB]) have a protective effect on kidney function. Based on this evidence, the eighth report of the Joint National Committee (JNC 8) recommends the use of these agents in patients with hypertension and CKD, with or without diabetes. The blood pressure goal recommended by the JNC 8 and the American Diabetes Association is <140/90 mm Hg for adult patients with hypertension and diabetes.
Recommendations for more aggressive blood pressure goals of <130/80 mm Hg in this population have recently been tempered by the lack of efficacy in reducing mortality with lower blood pressure goals and an increase in adverse events related to antihypertensive agents. Thus, initial combination therapy is not warranted in this case. Furthermore, the combination of two renin-angiotensin system agents for antihypertensive management in the setting of diabetes and moderately increased albuminuria (formerly known as microalbuminuria) has not been shown to improve outcomes and is associated with higher rates of hyperkalemia and other adverse events.
Key Point
- The eighth report of the Joint National Committee recommends an ACE inhibitor or angiotensin receptor blocker for patients with hypertension and chronic kidney disease, with or without diabetes mellitus.
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