From the Guidelines
The patient's uncontrolled hypertension should be addressed immediately by administering their prescribed antihypertensive medication, and then the steroid shot can be given, with close monitoring of blood pressure before and after administration. Managing a patient with uncontrolled hypertension who needs a steroid shot for a rash requires careful consideration of both conditions. The patient's blood pressure is 170/110, which is significantly elevated, and according to the 2017 American College of Cardiology/American Heart Association hypertension guideline 1, this is considered stage 2 hypertension.
Key Considerations
- The patient lives an hour away and cannot just go take the medication and come back, so it's crucial to manage the situation effectively in the current setting.
- The steroid shot is necessary for the rash, but it's essential to consider the potential impact of steroids on blood pressure.
- The patient's antihypertensive medication should be administered as soon as possible to bring the blood pressure under control.
Management Plan
- Administer the patient's prescribed antihypertensive medication immediately to help lower the blood pressure.
- Monitor the patient's blood pressure closely before and after the steroid administration.
- Consider using a lower dose of steroid, such as 20mg of triamcinolone acetonide, if the patient's hypertension is severe (>180/110 mmHg) 1.
- Alternatively, use a topical steroid like clobetasol propionate 0.05% cream twice daily for 7-14 days if appropriate for the rash type.
- Educate the patient about limiting sodium intake, maintaining adequate hydration, and avoiding NSAIDs while on steroids, as these can further elevate blood pressure.
Follow-up
- Monitor the patient's blood pressure daily for 1-2 weeks after steroid administration, as steroids can cause fluid retention and sodium retention, potentially worsening hypertension.
- If the blood pressure rises significantly (>160/100 mmHg), contact the healthcare provider for possible antihypertensive medication adjustment 1.
From the Research
Management of Uncontrolled Hypertension
The patient's blood pressure is 170/110, which is considered a hypertensive urgency, but not an emergency as it is below 180/120 mmHg 2.
Treatment Approach
For hypertensive urgencies, a gradual lowering of blood pressure over 24-48 hours with an oral medication is the best approach, and an aggressive blood pressure lowering should be avoided 2.
Medication Options
Intravenous hydralazine and labetalol are commonly used to treat acute blood pressure elevations in hospitalized patients 3. However, the choice of specific drugs depends on the underlying causes of the crisis, patient's demographics, cardiovascular risk, and comorbidities 2.
Considerations for This Patient
Given the patient's situation, where she cannot take her blood pressure medication and needs a steroid shot for a rash, it is essential to consider the potential impact of the steroid shot on her blood pressure. The patient's blood pressure should be closely monitored after the steroid shot, and appropriate antihypertensive medication should be administered if necessary.
Potential Antihypertensive Medications
IV hydralazine has been shown to result in a significant drop in blood pressure following severe hypertension, while metoprolol and amlodipine did not lower blood pressure in some studies 4. However, metoprolol has been used successfully in other cases to treat hypertensive emergencies 5.
Key Points to Consider
- The patient's blood pressure should be closely monitored after the steroid shot.
- Appropriate antihypertensive medication should be administered if necessary.
- The choice of specific drugs depends on the underlying causes of the crisis, patient's demographics, cardiovascular risk, and comorbidities.
- A gradual lowering of blood pressure over 24-48 hours with an oral medication is the best approach for hypertensive urgencies 2.