From the Guidelines
The patient should contact their healthcare provider immediately to report nausea and visual disturbances, as these symptoms may be related to their current medication regimen, particularly amlodipine, clonidine, or metoprolol, and adjustments may be necessary to prevent further morbidity and mortality. The patient's symptoms could be indicative of hypotension, a potential side effect of the combination of multiple blood pressure medications, including amlodipine, clonidine, hydrochlorothiazide, losartan, and metoprolol 1. According to a 2022 review by the European Society of Cardiology, calcium channel blockers like amlodipine can cause greater antihypertensive effects due to decreased baroreceptor response and age-related increase in drug exposure, leading to hypotension and other adverse effects 1.
Potential Causes and Solutions
- The patient's medication regimen includes several drugs that can contribute to nausea and visual disturbances, such as amlodipine, clonidine, and metoprolol.
- Reducing the dose of amlodipine from 10mg to 5mg daily or switching to a different antihypertensive medication with fewer side effects may help alleviate these symptoms.
- The patient should monitor their blood pressure at home and keep a symptom diary to help their provider determine which medication is most likely causing the problems.
- Considering the patient's complex medication regimen, it is essential to prioritize their quality of life and adjust their medications accordingly to minimize adverse effects.
Guidance on Next Steps
- The patient should not discontinue any medications without medical guidance.
- Their provider may consider alternative treatments or adjustments to their current regimen to mitigate nausea and visual disturbances.
- A recent study on antiemetics suggests that adult patients who experience nausea or vomiting despite optimal prophylaxis may be offered olanzapine in addition to continuing their standard antiemetic regimen 1.
- However, in the context of this patient's medication regimen and potential hypotension, it is crucial to prioritize adjustments to their antihypertensive medications over adding new medications for nausea.
From the FDA Drug Label
Gastrointestinal: Abdominal pain, anorexia, constipation, hepatitis, malaise, mild transient abnormalities in liver function tests, nausea, parotitis, pseudo-obstruction (including colonic pseudo-obstruction), salivary gland pain, and vomiting. Central Nervous System: Agitation, anxiety, delirium, delusional perception, hallucinations (including visual and auditory), insomnia, mental depression, nervousness, other behavioral changes, paresthesia, restlessness, sleep disorder, and vivid dreams or nightmares. Ophthalmological: Accommodation disorder, blurred vision, burning of the eyes, decreased lacrimation, and dryness of eyes
The patient's symptoms of nausea and visual disturbances may be related to the use of clonidine, as nausea is listed as a gastrointestinal adverse effect and visual disturbances are mentioned under the central nervous system and ophthalmological adverse effects 2.
From the Research
Patient Symptoms
The patient is experiencing nausea and visual disturbances.
- Nausea is a common symptom that can be associated with various medications, including those listed in the patient's medication regimen.
- Visual disturbances, including hallucinations, have been reported in patients taking metoprolol, as seen in the study 3.
Medication Review
The patient's medication regimen includes:
- Metoprolol Succinate ER Oral 25 MG, which has been associated with visual hallucinations 3.
- Other medications that may contribute to nausea, such as hydroCHLOROthiazide, Losartan Potassium, and Diclofenac Sodium.
Nausea Management
According to the studies 4, 5, and 6, nausea can be managed with:
- Antiemetic drugs for acute nausea and vomiting.
- Nonpharmacologic management options, such as fluid and electrolyte replacement, small frequent meals, and avoidance of trigger foods.
- Pharmacologic therapy targeting the suspected cause of symptoms and the neurotransmitters involved in central and peripheral pathways of nausea and vomiting.
Visual Disturbances
The study 3 suggests that metoprolol-induced visual hallucinations may be under-recognized and under-reported.
- Clinicians should maintain diligent surveillance when managing patients receiving metoprolol.
- Discontinuation of metoprolol may resolve visual disturbances, as seen in the case reports 3.
Other Considerations
The patient is also taking clonidine, which has been compared to metoprolol in the prophylactic treatment of migraine 7.
- However, this study does not provide direct relevance to the patient's current symptoms of nausea and visual disturbances.