What medications cause increased Intracranial Pressure (ICP)?

From the Guidelines

Corticosteroids, particularly when withdrawn abruptly, are a well-documented cause of increased intracranial pressure (ICP), and their use should be carefully managed to avoid this complication. Several medications can cause increased ICP, including:

• Corticosteroids (when withdrawn abruptly) 1
• Tetracycline antibiotics, particularly minocycline
• Vitamin A and related compounds (retinoids) in high doses
• Growth hormone therapy
• Oral contraceptives
• Nalidixic acid (an antibiotic)
• Lithium
• Some chemotherapy drugs

It's essential to note that the risk and severity of increased ICP can vary depending on the specific medication, dosage, and individual patient factors. The mechanism behind this effect often involves altering cerebrospinal fluid (CSF) production or absorption, or affecting cerebral blood flow. According to the 2010 update by the Infectious Diseases Society of America, acetazolamide and corticosteroids should be avoided to control increased intracranial pressure 1.

If a patient is taking any of these medications and experiences symptoms such as severe headaches, vision changes, or nausea, they should seek medical attention immediately. Healthcare providers should monitor patients on these medications closely, especially those with pre-existing conditions that may predispose them to increased ICP. In many cases, discontinuing the offending medication can resolve the issue, but this should always be done under medical supervision. Alternative treatments may need to be considered to manage the original condition while avoiding the risk of increased ICP. The most recent guideline from 2018 does not specifically address ICP but highlights the importance of careful medication management in patients with high blood pressure, which can be a related concern 1.

From the FDA Drug Label

Intracranial hypertension (IH, pseudotumor cerebri) has been associated with the use of tetracyclines including Achromycin V. Clinical manifestations of IH include headache, blurred vision, diplopia, and vision loss; papilledema can be found on fundoscopy Women of childbearing age who are overweight or have a history of IH are at greater risk for developing tetracycline associated IH. Concomitant use of isotretinoin and tetracycline should be avoided because isotretinoin, a systemic retinoid, is also known to cause pseudotumor cerebri.

The medications that can cause increased Intracranial Pressure (ICP) are:

• Tetracyclines, including Achromycin V
• Isotretinoin, a systemic retinoid, when used concomitantly with tetracyclines 2

From the Research

Medications Causing Increased Intracranial Pressure (ICP)

• The following medications have been associated with increased ICP:
  • Vitamin A derivatives, tetracycline-class antibiotics, recombinant growth hormone, and lithium are strongly associated with drug-induced intracranial hypertension (DIIH) 3
  • Corticosteroids are moderately associated with DIIH 3
  • Cyclosporine, progestin-only contraceptives, combined oral contraceptives, second- and third-generation fluoroquinolones, sulfenazone, gonadotropin-releasing hormones and luteinizing hormone-releasing hormone agonist, nalidixic acid, amiodarone, stanozolol, danazol, divalproic acid, sulfasalazine, ketoconazole, and ustekinumab are weakly associated with DIIH 3
• Specific cases of increased ICP have been reported with the use of:
  • Corticosteroids, which can cause benign intracranial hypertension, particularly when the dosage is reduced 4
  • Betamethasone, which has been shown to decrease the maximum pressure and amplitude of intracranial pressure in patients with hydrocephalus 5
• It is essential to note that the relationship between these medications and increased ICP is complex and may depend on various factors, including the specific medication, dosage, and individual patient characteristics 3, 6, 7