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National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2004 Aug.

Cover of The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

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Drugs and Other Agents Affecting Blood Pressure

Many prescription drugs and some over-the-counter agents and herbal supplements may affect BP and complicate BP control in treated hypertensive individuals. Consequently, searching for the presence of these agents in a person's medical history can identify a "secondary" component contributing to BP elevation. Such recognition may negate the need to employ unnecessary and potentially hazardous testing.

Use of agents that can affect BP in a given patient should be suspected in the following situations: (1) loss of control of previously well-controlled hypertension; (2) presence of comorbidities (particularly osteoarthritis); (3) biochemical evidence of intercurrent drug usage (such as an increase in serum potassium or creatinine concentrations with nonsteroidal anti-inflammatory drugs); and (4) atypical hypertension (such as severe but transient hypertension in a young patient presenting with chest pain and ECG changes accompanying possible cocaine usage).

Table 24 provides a list of agents that may alter BP. They may affect BP in several ways, such as affecting sodium balance; increasing adrenergic or suppressing parasympathetic neural activity; altering the production, release, or effectiveness of vasoactive hormones; or exerting direct effects on the endothelium or vascular smooth muscle.

Table 24. Common substances associated with hypertension in humans.

Table 24

Common substances associated with hypertension in humans.

Alcohol

Modest consumption of alcohol (e.g., <30 grams of ethanol a day or approximately two "drinks" daily) is not generally associated with BP increases. Larger amounts of alcohol ingestion have a dose-related effect on BP, both in hypertensive and normotensive subjects.10 The use of ABPM has highlighted the biphasic effects of alcohol on BP, underscoring the importance of the timing of BP measurement. A large intake of alcohol (>30 grams) may lower BP in the first 4 hours after ingestion. Approximately 10–15 hours later (perhaps at the time a patient is seen for an office visit or in the ER during withdrawal), BP increase may be noted. This accounts for some of the discrepancies reported in the literature about alcohol's effect on BP. The mechanism(s) of alcohol's effect on BP are unclear but appear predominantly to result from sympathetic neural activation, although changes in cortisol and cellular calcium concentrations also may play a role.

Nonaspirin Nonsteroidal Anti-Inflammatory Drugs

Nonaspirin nonsteroidal anti-inflammatory drugs (NANSAIDs) represent one of the most common medication classes consumed by hypertensive patients. Among the NANSAIDs, older agents like Indomethacin are the most extensively studied. BP responses vary within the class of the NANSAIDs; however, increases in pressure are often accompanied by peripheral edema and weight gain, supporting a salt-retention mechanism of hypertension associated with the loss of natriuretic prostaglandins such as PGE2.368,369 Reduction in the well-described vasodilatory effects of some prostaglandins are another mechanism. Cyclooxygenase-2 (COX-2) inhibitors also may cause elevation in BP.370–372 Recently, a double-blind randomized trial was conducted evaluating the effects of celecoxib, rofecoxib, and naproxen on 24-hour BP in type 2 diabetic patients with osteoarthritis whose hypertension was treated with ACEIs or ARBs. At equally efficacious doses for the management of osteoarthritis, treatment with rofecoxib (but not celecoxib or naproxen) induced a significant increase in average 24-hour SBP in type 2 diabetic patients receiving ACEIs or angiotensin-II receptor blockers.373 Thus, current data suggest that certain NSAIDs and COX-2 inhibitors may have destabilizing effects on BP control in diabetic hypertensive patients. This is a major concern because diabetic patients are often older and obese, and both obesity and aging predispose to osteoarthritis as well as diabetes.

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