Pearls of Wisdom: Could Lasix Help to Control Hypertension?

John is a 62-year-old male who has been treated with lisinopril and amlodipine to control blood pressure (BP). To date, he has only been able to get his BP down to 160/100 mm Hg with the combination of those 2 agents.

A trial addition of hydrochlorothiazide helped reduce his blood pressure to 136/84 mm Hg, within the target range, but it caused erectile dysfunction–so the patient declined to take it again. As a next step, you are considering adding a beta-blocker or clonidine.

At this point, John mentions that when he first started taking amlodipine, low-dose furosemide (Lasix, 20 mg/qd) had not only gotten rid of the edema he experienced on amlodipine, but also brought his blood pressure down considerably.

Is it worth trying prescribing Lasix again?

A. Don’t be ridiculous. Lasix is an acronym for “lasts six hours,” so that wouldn’t be a rational choice for hypertension.

B. It will lower blood pressure modestly, but it would require 3 to 4 doses a day to give 24-hour coverage, and therefore, would not be useful.

C. It might work, but tachyphylaxis will develop once the level of diuresis reaches a steady state—thus, negating the blood pressure effect.

D. It might work.

What is the correct answer?
(Answer and discussion on next page)

Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.

Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.

Answer: It might work

Most references on the treatment of hypertension do not even include furosemide. Yet, its mention in an old textbook on hypertension prompted me to look further.

The Research

A clinical trial performed in senior citizens (mean age 73 years) studied patients whose hypertension was not controlled on one or more medications.¹ Exclusions from the trial included known secondary hypertension (eg, hyperthyroidism, hyperaldosteronism), markedly elevated blood pressure (>220/110 mm Hg), heart failure (NYHA III-IV), chronic kidney disease (creatinine > 2.0 mg/dL), or already being treated with a diuretic. Admittedly, the study was quite small (n=12), but we have individual patient data, which looks convincing.
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The Results

Outcomes in the 12 patients were all favorable. Background medications typically included ACE inhibitors, beta-blockers, and calcium channel blockers. 

Baseline BP ranged from 150-205 mm Hg systolic and 70-100 mmHg diastolic (Tables). Doses of furosemide ranged from 20 mg/d to 60 mg/d (mean dose = 33 mg/d), but only 2 of the 12 patients enrolled in the trial required more than 40 mg/d of Lasix to produce a meaningful BP drop.

Effectiveness of Furosemide in HTN¹

The authors concluded that adding furosemide, in combination with the participants' other drugs, effectively reduced BP in all participants.

What’s The Take Home?

Lasix may be a neglected option for treatment of hypertension. It is available generically, has wide dosage flexibility, and is usually well tolerated.

Reference:
1. Vlase HL, Panagopoulos G, Michelis MF. Effectiveness of furosemide in uncontrolled hypertension in the elderly. Am J Hypertens. 2003;15:187-193.