Version August 2025
ANSWER —
Correct.
Lisinopril is an appropriate agent for this patient, who has systolic hypertension, diabetes, and microalbuminuria. The patient is already on this medication, and it is well tolerated without hyperkalemia, a deterioration of kidney function, cough, or other complications. It is appropriate to administer this drug at bedtime, in relation to the time of day when the patient is supine, to maximize its benefits and minimize the risk of recurrent symptoms of orthostatic hypotension. Continuing the same dose but giving it at a different time minimizes the risk of harm. If this change of timing is tolerated, one can then increase the dose slowly using small increments as tolerated.
In the patient under consideration, the change in time of administration of lisinopril to bedtime resulted in a small decrease in supine blood pressure readings to 177 to 187/69 to 77 mmHg with little or no change in upright blood pressure readings and no recurrence of symptoms.
A goal for supine systolic blood pressure readings of 160 mmHg was chosen. This is a value that was tolerated by the patient after the cessation of alfuzosin and hydrochlorothiazide and is approximately 20 mmHg below current readings. It is higher than the office goal of 125 to 130 mmHg, which is targeted only if it can be achieved without a reduction in the diastolic pressure to <55 to 60 mmHg in older adults with orthostatic hypotension (see "Treatment of hypertension in older adults, particularly isolated systolic hypertension"). The dose of lisinopril at bedtime was increased incrementally to 15 mg and two weeks later to 20 mg. The supine blood pressure readings fell to 156 to 168/68 to 78 mmHg with no appreciable change in upright blood pressure readings and without recurrence of symptoms.
Evaluation and management of this patient is discussed further in the comment card. (See "Interactive diabetes case 20: A 76-year-old patient with longstanding type 2 diabetes, orthostatic hypotension, and recurrent syncope – Comment".)
