Maximum dose of HCTZ

The maximum dose of HCTZ for the treatment of hypertension is typically listed as 50 mg per day. However, there is minimal "bang for the buck" for doses over 25 mg. In some studies, increasing the dose from 25 mg to 50 mg only reduced the systolic blood pressure by 4 mm. In my private practice, I typically max out HCTZ at 25 mg per day for the treatment of hypertension. If the patient is still not at goal at that dose, I typically add another medication.

Blood Pressure Medications

Most blood pressure medications, even at maximal dose, will only bring down the systolic blood pressure by 10-15 mm. So the tip of the day is this: consider starting TWO blood pressure medications (i.e. lisinopril and hydrochlorothiazide) for patients who are newly diagnosed with hypertension AND who have a systolic blood pressure > 160.

Bilateral Pedal Edema

When a patient presents with new-onset bilateral pedal edema (especially with elevated blood pressure), I make it a habit to check a UA looking for proteinuria. Every once in a while, I catch a new case of nephrotic syndrome that way—since peeing out your albumin (and other proteins) will definitely cause extra-vascular edema from reduced inter-vascular oncotic pressure.

ACE Inhibitors and Birth Defects

As family doctors are diagnosing diabetes and hypertension earlier and earlier, the use of ACE Inhibitors in younger patients is becoming more common. However, it is good to be reminded that ACE Inhibitor may be associated with an increased risk of birth defects (and currently this is a black-boxed warning). For woman of childbearing age, options other than ACE Inhibitors should be considered. So when we get that fax from the insurance company urging us to start an ACE Inhibitor for our young, diabetic, female patient, we should feel free to tell them to bugger off.