Medications and supplements induced hypertension
Overview
Patients are often surprised when they learn they're taking medications that can INCREASE blood pressure or induced hypertension (HTN). Check for common culprits if patients have new or worsening high blood pressure. Explain that most patients won't have a significant blood pressure increase with these medications, but some could see a 5 to 10 mmHg bump in systolic blood pressure.
Approach
Medications induced hypertention
- NSAIDs: An occasional NSAID is okay in most patients, but advise limiting NSAID dose and duration in patients at high cardiovascular (CV) risk. Or suggest acetaminophen or a topical NSAID (Voltaren gel, etc) for local pain.
- Decongestants: A few doses of pseudoephedrine are okay if BP is controlled. It usually only increases blood pressure about 2 mmHg. But suggest up to 3 days of a topical decongestant (oxymetazoline, etc) or nondrug options (saline nasal spray, etc) if BP is uncontrolled. Oral phenylephrine doesn't seem to increase blood pressure, but it also isn't likely to help congestion.
- SNRIs: If one is needed, advise sticking with moderate doses, such as less than 225 mg/day of venlafaxine or 100 mg/day of milnacipran. Or suggest an SSRI instead if appropriate. These don't raise blood pressure.
- ADHD medications: If a stimulant or atomoxetine increases blood pressure, consider suggesting guanfacine (Intuniv, etc) or clonidine (Kapvay, etc) for ADHD instead "these medications NOT available in Egypt", or continuing the stimulant and treating the elevated blood pressure.
- Estrogen contraceptives: Recommend a progestin-only or nonhormonal contraceptive if a combination oral contraceptive, patch, or ring causes blood pressure concerns.
- Caffeine: Dispel the myth that regular intake of one to 2 cups of coffee or 200 to 300 mg/day of caffeine increases blood pressure. But explain that occasional use or higher amounts can bump blood pressure for about 3 hours.
- Supplements: Steer patients away from supplements that may increase blood pressure, such as those with bitter orange, guarana, or licorice root.
Encourage patients to monitor blood pressure if a risky medication is started especially in a higher-risk patient with hypertension or cardiovascular (CV) risk factors. Recommend the usual first-line antihypertensives if a medication is needed. But for increased blood pressure due to chronic NSAIDs, consider suggesting a CCB (amlodipine, etc), their BP-lowering effects aren't offset by NSAIDs.
References
- Lovell AR, Ernst ME. Drug-Induced Hypertension: Focus on Mechanisms and Management. Curr Hypertens Rep. 2017 May;19(5):39.
- Salerno, S.M., Jackson, J.L. and Berbano, E.P. (2005). Effect of Oral Pseudoephedrine on Blood Pressure and Heart Rate. Archives of Internal Medicine, 165(15), p.1686.
- Schmidt, M., Lamberts, and others (2016). Cardiovascular safety of non-aspirin non-steroidal anti-inflammatory drugs: review and position paper by the working group for Cardiovascular Pharmacotherapy of the European Society of Cardiology. European Heart Journal, [online] 37(13), pp.1015–1023.
