A patient with resistant hypertension and low potassium levels is managed with spironolactone. What is the best next step?

In the management of resistant hypertension, especially in patients with low potassium levels, the goal is to effectively control blood pressure while addressing any electrolyte imbalances. In this context, spironolactone, a potassium-sparing diuretic, is particularly useful because it can help retain potassium while promoting diuresis.

Starting spironolactone at 12.5 mg/day is a suitable next step for several reasons. This dose can provide a background of aldosterone antagonism, which is beneficial in patients with resistant hypertension, especially those who may also have primary hyperaldosteronism or heart failure. Additionally, in cases where potassium levels are low, initiating treatment with spironolactone can help stabilize those levels, as it may help prevent further potassium loss while contributing to blood pressure control.

Furthermore, if the patient is already on other antihypertensives or diuretics, titrating an existing medication such as indapamide, increasing a beta-blocker dose, or starting a new class of medications like terazosin may not adequately address the patient’s hypertension while also considering the potassium issue. Therefore, escalating the dose of spironolactone is both a rational and effective approach in this scenario.