What are the next steps for a patient started on venlafaxine (Effexor) 37.5mg and aripiprazole (Abilify) who develops hypertension?

From the Guidelines

If your patient's blood pressure has increased after starting venlafaxine 37.5 mg and aripiprazole, you should monitor their blood pressure closely and consider dose adjustment or medication changes, prioritizing the patient's cardiovascular health and overall quality of life. First, confirm the elevation with repeated measurements and determine if it's clinically significant. Venlafaxine is known to cause dose-dependent increases in blood pressure through its noradrenergic effects, particularly at higher doses 1. If the hypertension is mild, continue monitoring while the patient's body adjusts to the medication, as some side effects diminish over time. For moderate to severe hypertension, consider reducing the venlafaxine dose or switching to an alternative antidepressant with less impact on blood pressure, such as an SSRI, as suggested by the guidelines for managing high blood pressure in adults 1. Aripiprazole typically has minimal effects on blood pressure, but individual responses vary. Ensure the patient is following proper lifestyle measures like:

• limiting sodium
• maintaining healthy weight
• exercising regularly
• avoiding substances that can elevate blood pressure, such as alcohol, amphetamines, and certain herbal supplements 1. If hypertension persists despite these measures, consult with the patient's primary care provider about adding antihypertensive medication while continuing psychiatric treatment, aiming to achieve a blood pressure target of less than 130/80 mmHg, as recommended by the American Heart Association and the American Diabetes Association 1.

From the FDA Drug Label

Venlafaxine treatment is associated with sustained increases in blood pressure in some patients An analysis for patients meeting criteria for sustained hypertension (defined as treatment-emergent SDBP ≥ 90 mm Hg and ≥ 10 mm Hg above baseline for 3 consecutive visits) revealed a dose-dependent increase in the incidence of sustained hypertension for venlafaxine For patients who experience a sustained increase in blood pressure while receiving venlafaxine, either dose reduction or discontinuation should be considered Pre-existing hypertension should be controlled before treatment with venlafaxine. It is recommended that patients receiving venlafaxine have regular monitoring of blood pressure

Key Considerations:

• The patient's blood pressure should be monitored regularly while taking venlafaxine.
• If the patient experiences a sustained increase in blood pressure, either dose reduction or discontinuation of venlafaxine should be considered.
• Pre-existing hypertension should be controlled before starting treatment with venlafaxine.
• Given that the patient's blood pressure has increased, it is recommended to:
  • Monitor the patient's blood pressure closely.
  • Consider dose reduction of venlafaxine.
  • If necessary, consider discontinuation of venlafaxine.
  • Consult with the patient's healthcare provider to determine the best course of action 2

From the Research

Patient's High Blood Pressure

• The patient's blood pressure has increased after starting venlafaxine 37.5 and aripiprazole, which may be related to the venlafaxine treatment 3.
• Venlafaxine can cause elevated blood pressure, particularly at high doses, due to its noradrenergic potentiation effects 4.

Managing High Blood Pressure

• Close monitoring of blood pressure is necessary after initiation of venlafaxine treatment to prevent end-organ damage 3.
• The selection of antihypertensive therapies should be based on the presence of concomitant cardiovascular and metabolic conditions, as well as patient-specific factors such as race 5.
• Combination therapy with two or more antihypertensive agents from different pharmacologic classes may be necessary to achieve adequate blood pressure control 6, 7.

Treatment Options

• Thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) are commonly used in combination therapy for hypertension 6.
• ACEIs and ARBs should not be used simultaneously, and patients with heart failure or chronic kidney disease may require specific combination therapies 6.
• Single-dose combination antihypertension therapy can be an effective option for enhancing compliance and reducing side effects 7.