USMLE Step 2 - Question 20

A 50 year old male with a history of diabetes mellitus presents for a routine clinic visit. He has been feeling well and has no complaints. He has been exercising regularly and dieting as instructed for his diabetes. His medications include metformin and glypizide. His blood pressure is 180/90, heart rate 70, and respirations 20. His physical examination is normal. Which of the following is the most appropriate management at this time?

A. Continue diet and lifestyle modifications for 6 months

B. Start lisinopril and hydrochlorothiazide

C. Start amlodipine

D. Start hydrochlorothiazide

E. Start spironolactone

According to the JNC VII guidelines, stage II hypertension (which is systolic blood pressure >160 or diastolic blood pressure >100) will require 2 medications for therapy. The even make the more general statement that a majority of all patients with hypertension will require 2 medications. Remember that first line medications for hypertension include thiazide diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, and angiogtensin receptor blockers. Medications such as clonidine, alpha-blockers, direct arterial vasodilators (hydralazine or minoxidil), and non-thiazide diuretics such as spironolactone are not indicated first line and should only be used if there is a compelling indications (such as using spironolactone for New York Heart Associated functional class III or IV systolic heart failure).