DEAR DR. ROACH: I’m a 69-year-old woman who’s been on different blood pressure medications for a very long time. I was on 20 mg of lisinopril and 5 mg of amlodipine for a while, but my blood pressure spiked to 190/100 mm Hg. My doctor then increased the amlodipine to 10 mg, which brought my blood pressure down somewhat, but I still was often in the 150-170 range.

I also had a fast heart rate often, so metoprolol (50 mg) was substituted for amlodipine. This didn’t really work, so 12.5 mg of hydrochlorothiazide (HCTZ) was added. Now I’m suddenly having low blood pressure.

Do you have any suggestions as to how to manage this balancing act?

— D.H.

ANSWER: Even though you aren’t having any symptoms, this isn’t ideal blood pressure treatment. Most people in their 60s and 70s should have a treated systolic blood pressure that averages in the 120s. People who are at a high risk for heart disease or strokes should have a systolic blood pressure that is less than 120 mm Hg.

It seems that HCTZ really worked for you, even at the lowest dose, when it was added to the lisinopril and metoprolol. If you were my patient, I would probably lower the lisinopril down to 10 mg and see if this gets you into the ideal blood pressure range. Lisinopril can also be dosed at 5 and 2.5 mg.

I find, and most experts agree, that a combination of blood pressure medicines at low or medium doses is more effective and has fewer side effects than one blood pressure medicine.

DEAR DR. ROACH: I’ve read that once you stop PPIs, you have a rebound effect, and symptoms reappear. This doesn’t happen with cimetidine. Can you explain this to me?

— L.T.

ANSWER: The hormone gastrin stimulates the stomach to make more acid. Gastrin, in turn, is stimulated when the stomach isn’t as acidic as it should be. Proton-pump inhibitors such as omeprazole (Prilosec) stop the protein that makes acid, causing the stomach to become almost neutral in pH. This neutral pH stimulates gastrin, which is then supposed to stimulate the acid-producing cells in the stomach.

However, even with high gastrin levels, the PPI is still effective at blocking acid secretion. Over time, the number of acid-producing cells will increase as the body tries to adapt to the continued PPI. If the PPI is suddenly stopped, the increased acid-producing capacity of the stomach goes into “overdrive,” causing high amounts of acid that can lead to symptoms.

ToYourGoodHealth@med.cornell.edu.