What medications should be held or adjusted in a patient with hypotension?

From the Guidelines

In patients with hypotension, antihypertensive medications such as ACE inhibitors, ARBs, calcium channel blockers, beta-blockers, and diuretics should be temporarily suspended to prevent worsening of low blood pressure. The medications that should be held or adjusted include:

• ACE inhibitors (lisinopril, enalapril)
• ARBs (losartan, valsartan)
• Calcium channel blockers (amlodipine, diltiazem)
• Beta-blockers (metoprolol, carvedilol)
• Diuretics (furosemide, hydrochlorothiazide)
• Vasodilators such as nitrates (nitroglycerin, isosorbide) Certain psychiatric medications with hypotensive effects like clozapine, quetiapine, and tricyclic antidepressants may need dose reduction 1. Opioid analgesics, benzodiazepines, and anesthetic agents should be used cautiously with reduced dosing. For patients on multiple blood pressure medications, consider holding the longest-acting agent first. When blood pressure stabilizes, medications can be gradually reintroduced at lower doses with careful monitoring, as suggested by guidelines for managing heart failure and myocardial infarction 1. The rationale for these adjustments is that these medications can exacerbate hypotension through various mechanisms including vasodilation, decreased cardiac output, reduced intravascular volume, or direct cardiac depression, potentially leading to inadequate organ perfusion and tissue hypoxia. It is essential to prioritize the patient's blood pressure stability and adjust medications accordingly to minimize the risk of complications. In clinical practice, the management of hypotension requires careful consideration of the patient's overall clinical condition, including the presence of heart failure, myocardial infarction, or other comorbidities, as well as the potential interactions between different medications 1.

From the FDA Drug Label

If hypotension occurs (systolic blood pressure ≤ 100 mmHg) a daily maintenance dose of 5 mg may be given with temporary reductions to 2.5 mg if needed. If prolonged hypotension occurs (systolic blood pressure < 90 mmHg for more than 1 hour) lisinopril tablets should be withdrawn. Diuretic dose may need to be adjusted to help minimize hypovolemia, which may contribute to hypotension

The medications that should be held or adjusted in a patient with hypotension are:

• Lisinopril: may need to be temporarily reduced to 2.5 mg or withdrawn if prolonged hypotension occurs
• Diuretics: dose may need to be adjusted to minimize hypovolemia and contribute to hypotension 2

From the Research

Medications to Hold or Adjust for Hypotension

The following medications may need to be held or adjusted in a patient with hypotension:

• Alpha 1-blockers, such as prazosin, which can cause orthostatic hypotension, especially with the first dose 3
• Adrenergic blockers, including beta-blockers like propranolol and esmolol, which can also contribute to hypotension 4, 3
• Centrally acting drugs, such as clonidine, which can lead to orthostatic hypotension 3
• ACE inhibitors, which can cause refractory hypotension during the perioperative period 5
• Diuretics, which can lead to hypovolemia and exacerbate hypotension 3, 6
• Calcium channel blockers, such as nicardipine, which can cause hypotension, especially when used in combination with other agents 4
• Antianginals and antiarrhythmics, which can also contribute to hypotension 3

Considerations for Medication Adjustment

When adjusting medications for hypotension, consider the following:

• The patient's medical history and current condition, including the presence of hypertension, heart failure, or other cardiovascular diseases
• The type and severity of hypotension, including orthostatic hypotension or refractory hypotension
• The potential interactions between medications and the risk of adverse effects, such as hypotension or bradycardia
• The use of combination antihypertensive therapy, which may require adjustment to achieve optimal blood pressure control 6

Alternative Treatment Options

In cases where hypotension is severe or refractory, alternative treatment options may be necessary, such as:

• Vasopressin or methylene blue for ACE inhibitor-associated refractory hypotension 5
• Fluid bolus or vasoactive medications, such as ephedrine or phenylephrine, to manage hypotension during the perioperative period 5