What medications have hypotensive adverse effects?

From the Guidelines

Medications that can lower blood pressure as a side effect include alpha-blockers, beta blockers, direct renin inhibitors, alpha-1 blockers, central alpha2-agonists, and direct vasodilators, as listed in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. These medications can cause hypotension through various mechanisms, including vasodilation, decreased sympathetic tone, or reduced blood volume. Some key medications to note include:

• Alpha-blockers like doxazosin, which can cause orthostatic hypotension, especially in older adults 1
• Beta blockers, such as atenolol and metoprolol, which can lower blood pressure but are not recommended as first-line agents unless the patient has ischemic heart disease or heart failure 1
• Direct renin inhibitors like aliskiren, which can increase the risk of hyperkalemia in patients with chronic kidney disease or those taking potassium supplements or potassium-sparing diuretics 1
• Central alpha2-agonists like clonidine, which can cause significant CNS adverse effects, especially in older adults, and should be tapered to avoid rebound hypertension 1
• Direct vasodilators like hydralazine, which can cause sodium and water retention and reflex tachycardia, and should be used with a diuretic and beta blocker 1 Patients taking these medications should be monitored for symptoms like dizziness, lightheadedness, or fainting, especially when standing up quickly, and dose adjustments or medication changes may be necessary for patients experiencing significant hypotension.

From the FDA Drug Label

WARNINGS As with all alpha-blockers, prazosin hydrochloride may cause syncope with sudden loss of consciousness. In most cases, this is believed to be due to an excessive postural hypotensive effect, although occasionally the syncopal episode has been preceded by a bout of severe tachycardia with heart rates of 120–160 beats per minute

More common than loss of consciousness are the symptoms often associated with lowering of the blood pressure, namely, dizziness and lightheadedness

Hypotension may develop in patients given prazosin hydrochloride who are also receiving a beta-blocker such as propranolol.

WARNINGS Excessive Hypotension Although in most patients the hypotensive effect of nifedipine is modest and well tolerated, occasional patients have had excessive and poorly tolerated hypotension.

The medications that have blood pressure lowering adverse effects are:

• Prazosin 2: may cause syncope, dizziness, lightheadedness, and hypotension, especially when used with beta-blockers.
• Nifedipine 3 and 3: may cause excessive hypotension, especially when used with beta-blockers or other medications that lower blood pressure.

From the Research

Medications with Blood Pressure Lowering Adverse Effects

• Certain antidepressant drugs can have adverse effects on blood pressure, including orthostatic hypotension and hypertensive crisis 4
• Monoamine oxidase inhibitors (MAOIs) can cause orthostatic hypotension or hypertensive crisis due to ingestion of tyramine-containing food 5, 4, 6
• Tricyclic antidepressants have been associated with increases in blood pressure, as well as orthostatic hypotension 4
• Selective serotonin reuptake inhibitors are characterized by limited effects on autonomic system activity and a lower impact on blood pressure, making them a safer option for patients with cardiovascular diseases 4
• Serotonin-norepinephrine reuptake inhibitors, particularly venlafaxine, carry a greater risk of hypertension 4

Antihypertensive Medications with Adverse Effects

• Certain blood pressure-lowering drugs have adverse effects on glucose homeostasis, and have been associated with the development of both prediabetes and diabetes during use 7
• The benefits of blood pressure reduction must be weighed against the hazards of dysglycemia that can lead to diabetes when using antihypertensive medications 7

Interactions with Other Medications

• MAOIs can negatively interact with both sympathomimetic and serotonergic drugs, and patients on a MAOI should avoid certain OTC medications that can interact adversely with MAOIs 5
• Combination therapy with MAOIs and other antidepressants or stimulants may be considered for the management of treatment-resistant depression, but requires close supervision and careful consideration of potential risks 8