What is the effect of decongestants on hypertension (high blood pressure)?

From the Guidelines

Decongestants should be used with caution in patients with hypertension, and alternative therapies should be considered to minimize the risk of exacerbating hypertension. When managing nasal congestion in hypertensive patients, it is essential to weigh the benefits and risks of decongestant use. Oral decongestants like pseudoephedrine and phenylephrine can increase blood pressure by stimulating alpha-adrenergic receptors, causing vasoconstriction 1. According to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline, decongestants should be used for the shortest duration possible and avoided in severe or uncontrolled hypertension 1. Some key points to consider when using decongestants in hypertensive patients include:

• Safer alternatives, such as saline nasal sprays, intranasal corticosteroids (like fluticasone, mometasone, or budesonide), and antihistamines without decongestant properties (such as loratadine, cetirizine, or fexofenadine), should be considered 1.
• Topical nasal decongestants like oxymetazoline (Afrin) may be used for very short periods (no more than 3 days) with close blood pressure monitoring, though they still carry some risk 1.
• Non-pharmacological approaches, such as using a humidifier, nasal irrigation with saline solution, and staying well-hydrated, can also help manage congestion without affecting blood pressure 1. It is crucial to prioritize the patient's blood pressure management and consider the potential risks and benefits of decongestant use in hypertensive patients.

From the FDA Drug Label

In patients with end stage renal disease (ESRD) undergoing hemodialysis, dose-response data indicates increased responsiveness to phenylephrine. Overdose of phenylephrine hydrochloride injection 10 mg/mL can cause a rapid rise in blood pressure Symptoms of overdose include headache, vomiting, hypertension, reflex bradycardia, and cardiac arrhythmias including ventricular extrasystoles and ventricular tachycardia, and may cause a sensation of fullness in the head and tingling of the extremities. Phenylephrine hydrochloride is an α-1 adrenergic receptor agonist. Following parenteral administration of phenylephrine hydrochloride, increases in systolic blood pressure, diastolic blood pressure, mean arterial blood pressure, and total peripheral vascular resistance are observed Inform patients, families, or caregivers that the primary side effect of phenylephrine is hypertension and, rarely, hypertensive crisis

Decongestants in Hypertension:

• Phenylephrine can increase blood pressure due to its α-1 adrenergic receptor agonist properties.
• Hypertension is a primary side effect of phenylephrine, and it can rarely cause hypertensive crisis.
• Patients with end-stage renal disease (ESRD) may be more responsive to phenylephrine, which can lead to increased blood pressure.
• Overdose of phenylephrine can cause a rapid rise in blood pressure, leading to symptoms such as headache, vomiting, and cardiac arrhythmias.
• Therefore, caution should be exercised when using phenylephrine in patients with hypertension, and monitoring of blood pressure is recommended 2.

From the Research

Decongestants and Hypertension

• The use of decongestants in patients with hypertension has been a topic of debate due to their potential to increase blood pressure 3, 4.
• Studies have investigated the effects of pseudoephedrine on blood pressure in patients with controlled hypertension, with results showing no significant changes in blood pressure 5, 6.
• A review of clinical trials found that pseudoephedrine and phenylephrine appear to have non-significant effects on blood pressure in normotensive subjects when used at recommended oral doses as nasal decongestants 3.
• However, another study noted that the evidence to support the widespread belief that sympathomimetic decongestants are unsafe in hypertensive patients is weak and circumstantial 4.

Effects of Pseudoephedrine on Blood Pressure

• A randomized, placebo-controlled, crossover trial found that a single oral dose of pseudoephedrine (60 mg) did not change systolic and diastolic blood pressure and heart rate from baseline in hypertensive patients treated with beta-blockers 5.
• Another study found that therapeutic doses of pseudoephedrine did not adversely affect control of hypertension in patients with controlled, uncomplicated hypertension 6.
• A more recent study found that pseudoephedrine causes an average increase of 1.2 mm Hg in systolic blood pressure in patients with controlled hypertension, but the studies are not adequately powered to provide evidence about whether this rise in systolic BP is linked to patient-oriented outcomes 7.

Safety of Decongestants in Hypertension

• The safety of oral decongestants in patients with hypertension remains unclear, with some studies suggesting that they may be safe in patients with controlled hypertension 5, 6.
• However, other studies have noted that the evidence is limited and that further investigations are needed to fully assess the safety of decongestants in hypertensive patients 3, 4.
• It is recommended that patients with hypertension use decongestants with caution and under the guidance of a healthcare professional 7.