As a pharmacy specialist, patients will ask you about medications and supplements that may cause hypertension. They are often surprised when they learn they're taking medications that can INCREASE blood pressure (BP). Check for common culprits if patients have new or worsening high BP. Explain that most patients won't have a significant BP increase with these medications, but some could see a 5 to 10 mmHg bump in systolic BP.
- 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 (Panadol, Tylenol) or a topical NSAID like diclofenac gel (Voltaren gel, etc) for local pain.
- Decongestants. A few doses of pseudoephedrine are okay if BP is controlled, it usually only increases BP 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 BP, 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 BP.
- ADHD medications. If a stimulant or atomoxetine increases BP, consider suggesting guanfacine (Intuniv, etc) or clonidine (Kapvay, etc) for ADHD instead, or continuing the stimulant and treating the elevated BP.
- Estrogen contraceptives. Recommend a progestin-only or nonhormonal contraceptive if a combo oral contraceptive (OC), patch, or ring causes BP concerns.
- Caffeine. Dispel the myth that regular intake of one to 2 cups of coffee or 200 to 300 mg/day of caffeine increases BP. But explain that occasional use or higher amounts can bump BP for about 3 hours.
- Supplements. Steer patients away from supplements that may increase BP, such as those with bitter orange, guarana, or licorice root. Encourage patients to monitor BP if a risky med is started, especially in a higher-risk patient with hypertension or CV risk factors. Recommend the usual first-line antihypertensives if a medication is needed. But for increased BP due to chronic NSAIDs, consider suggesting a CCB (amlodipine, etc), their BP-lowering effects aren't offset by NSAIDs.
REFERENCES
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Lovell AR, Ernst ME. Drug-Induced Hypertension: Focus on Mechanisms and Management. Curr Hypertens Rep. 2017 May;19(5):39. Available at: https://pubmed.ncbi.nlm.nih.gov/28451850
Salerno SM, Jackson JL, Berbano EP. Effect of oral pseudoephedrine on blood pressure and heart rate: a meta-analysis. Arch Intern Med. 2005 Aug 8-22;165(15):1686-94. Available at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/765664
Schmidt M, Lamberts M, Olsen AM, Fosbøll E, Niessner A, Tamargo J, Rosano G, Agewall S, Kaski JC, Kjeldsen K, Lewis BS, Torp-Pedersen C. 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. Eur Heart J. 2016 Apr 1;37(13):1015-23. Available at: https://academic.oup.com/eurheartj/article/37/13/1015/2398407?login=false