What medications should be discontinued in a patient with hypotension?

From the Guidelines

In patients with hypotension, beta-blockers, especially those that also block alpha-1–receptors, such as carvedilol, should be discontinued or dose-reduced to prevent worsening of low blood pressure, as they can produce hypotension, which is usually asymptomatic but may produce dizziness, lightheadedness, or blurred vision 1.

Medications to Discontinue or Dose-Reduce

• Antihypertensive medications, including:
  • ACE inhibitors (lisinopril, enalapril)
  • Angiotensin receptor blockers (losartan, valsartan)
  • Calcium channel blockers (amlodipine, diltiazem)
  • Beta-blockers (metoprolol, carvedilol)
  • Diuretics (hydrochlorothiazide, furosemide)
• Other medications that can exacerbate hypotension, including:
  • Nitrates (nitroglycerin)
  • Phosphodiesterase inhibitors (sildenafil)
  • Alpha-blockers (tamsulosin, doxazosin)
  • Certain antidepressants (especially tricyclics like amitriptyline)
  • Antipsychotics (quetiapine, chlorpromazine)
  • Opioid analgesics

Considerations for Discontinuation or Dose-Reduction

• The decision to discontinue or dose-reduce should be based on the severity of hypotension, the patient's symptoms, and the indication for the medication.
• Some medications may need tapering rather than abrupt discontinuation, particularly beta-blockers, which can cause rebound hypertension or tachycardia if stopped suddenly 1.
• The underlying cause of hypotension should be addressed simultaneously, which may include volume resuscitation, treating infections, or addressing cardiac issues.
• Once blood pressure stabilizes, medications can be cautiously reintroduced at lower doses with careful monitoring.

Recent Guidelines

• 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 recommends careful consideration of medication management in patients with hypotension 1.
• The 2021 Standards of Medical Care in Diabetes recommend avoiding medications that aggravate hypotension and using pharmacologic measures to manage orthostatic hypotension 1.

From the FDA Drug Label

DRUG INTERACTIONS 7. 1 Diuretics Initiation of lisinopril in patients on diuretics may result in excessive reduction of blood pressure. The possibility of hypotensive effects with lisinopril can be minimized by either decreasing or discontinuing the diuretic or increasing the salt intake prior to initiation of treatment with lisinopril. 7. 4 Dual Blockade of the Renin-Angiotensin System (RAS) Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy. In most patients no benefit has been associated with using two RAS inhibitors concomitantly In general, avoid combined use of RAS inhibitors.

The medications that should be discontinued in a patient with hypotension are:

• Diuretics: Consider decreasing or discontinuing diuretics to minimize the possibility of hypotensive effects.
• Dual RAS inhibitors: Avoid combined use of RAS inhibitors, such as angiotensin receptor blockers, ACE inhibitors, or aliskiren, as they are associated with increased risks of hypotension. 2

From the Research

Medications to Discontinue for Hypotension

In patients with hypotension, certain medications may exacerbate the condition and should be discontinued or adjusted. The following medications have been associated with hypotension:

• Alpha 1-blockers, particularly with the first dose, as they can cause orthostatic hypotension 3
• Adrenergic blockers and centrally acting drugs, which are also known to cause orthostatic hypotension 3
• Drugs used for the treatment of psychiatric illnesses, such as:
  • Phenothiazines
  • Tricyclic antidepressants
  • Monoamine oxidase inhibitors, all of which have been associated with a significant incidence of orthostatic hypotension 3
• Cardiovascular drugs, including:
  • Dopamine agonists
  • Antianginals
  • Antiarrhythmics, which can contribute to hypotension 3

Considerations for Discontinuation

When considering discontinuing medications for hypotension, it is essential to weigh the potential benefits against the risks. Some studies suggest that temporary discontinuation of antihypertensive medication may be well-tolerated and not increase the risk of cardiovascular events 4. However, this decision should be made on a case-by-case basis, taking into account individual patient characteristics and medical history.

Alternative Treatments

For patients with orthostatic hypotension, alternative treatments may be considered, such as:

• Fludrocortisone, a mineralocorticoid that can increase blood volume and blood pressure 5
• Midodrine, an alpha-adrenoceptor agonist that has been shown to increase standing blood pressure and decrease orthostatic symptoms 6
• Other pressor drugs, such as octreotide, indomethacin, or ergotamine, which may be used to elevate standing blood pressure and/or orthostatic tolerance 6