Pharmacotherapy Case Study: Hypotension by Dr. Nehad Ahmed

 

Pharmacotherapy Case Study: Hypotension
Patient Profile: 70-year-old female

Subjective Data

  • Chief Complaint: “I feel dizzy when I stand up, and I almost fainted this morning.”
  • History of Present Illness:
    • Reports lightheadedness upon standing for 1 week, worsening in the mornings.
    • One episode of near-syncope today while getting out of bed.
    • Denies chest pain, palpitations, nausea, or diaphoresis.
  • Medical History:
    • Hypertension (diagnosed 10 years ago).
    • Osteoarthritis, GERD.
    • No history of diabetes, heart failure, or thyroid disorders.
  • Medications:
    • Lisinopril 20 mg daily.
    • Hydrochlorothiazide (HCTZ) 25 mg daily.
    • Metoprolol XL 50 mg daily.
    • Omeprazole 20 mg daily.
  • Adherence: Takes all medications in the morning; admits to occasional missed doses.
  • Social History:
    • Lives alone; sedentary due to osteoarthritis.
    • Poor oral intake (reports “not drinking much water”).
    • No smoking, alcohol, or illicit drug use.

Objective Data

  • Vitals:
    • Supine BP: 100/60 mmHg, HR 70 bpm.
    • Standing BP: 85/50 mmHg, HR 90 bpm (orthostatic drop >20/10 mmHg).
    • BMI: 22 kg/m², Temp: 98.2°F, SpO₂: 98% on room air.
  • Physical Exam:
    • Neurologic: Alert, oriented; no focal deficits.
    • Cardiovascular: Regular rate/rhythm, no murmurs.
    • Extremities: No edema; normal capillary refill.
    • Skin: Warm, dry; no tenting.
  • Labs:
    • Na⁺: 132 mEq/L (mild hyponatremia), K⁺: 3.6 mEq/L.
    • BUN: 28 mg/dL, Cr: 1.2 mg/dL (baseline Cr: 1.0 mg/dL).
    • Hb: 12.5 g/dL, TSH: 2.5 mIU/L (normal).
  • ECG: Normal sinus rhythm, no ischemic changes.

Assessment

  1. Primary Diagnosis:
    • Symptomatic Orthostatic Hypotension secondary to:
      • Medication-induced hypotension (lisinopril, HCTZ, metoprolol).
      • Volume depletion (poor oral intake, diuretic use).
  2. Contributing Factors:
    • Polypharmacy with antihypertensives.
    • Mild dehydration (elevated BUN/Cr ratio).
  3. Rule Out:
    • Adrenal insufficiency, anemia, arrhythmia (less likely given labs/ECG).

Pharmacotherapy Plan

  1. Medication Adjustments:
    • Discontinue hydrochlorothiazide (primary contributor to volume depletion).
    • Reduce lisinopril to 10 mg daily and metoprolol XL to 25 mg daily.
    • Monitor BP twice daily (seated/standing); avoid overcorrection to hypertension.
  2. Volume Replenishment:
    • Oral rehydration with electrolyte solutions; encourage increased fluid/salt intake.
  3. Considerations for Refractory Symptoms:
    • If hypotension persists, trial midodrine 2.5 mg TID (alpha-agonist for vasoconstriction).
    • Avoid fludrocortisone (risk of exacerbating hypertension long-term).
  4. Non-Pharmacologic Interventions:
    • Compression stockings to reduce venous pooling.
    • Postural education: Rise slowly from sitting/lying positions.

Monitoring & Follow-Up

  • 3-day follow-up: Recheck BP, orthostatic vitals, and creatinine.
  • 1-week follow-up: Assess medication tolerance and symptom resolution.
  • Labs: Repeat electrolytes and renal function in 1 week.

Patient Education

  • Emphasize hydration (goal: 6–8 glasses water/day) and small, salty snacks.
  • Instruct to take antihypertensives at bedtime if BP remains low in mornings.
  • Review signs of worsening hypotension (e.g., falls, confusion).

Rationale:

  • Discontinuing HCTZ and reducing antihypertensive doses address iatrogenic causes of hypotension.
  • Midodrine is reserved for refractory cases to improve vascular tone without fluid retention.
  • Hydration and lifestyle adjustments target volume depletion and prevent recurrence.

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