What medications are bad for pulmonary hypertension?

Medications to Avoid in Pulmonary Hypertension

Calcium channel blockers should be avoided in patients with pulmonary hypertension who have not demonstrated positive acute vasoreactivity testing, as they can cause severe hemodynamic compromise and potentially death. 1

Dangerous Medications in Pulmonary Hypertension

Calcium Channel Blockers

• Only indicated for the small subset of patients who demonstrate positive acute vasoreactivity testing during right heart catheterization 1
• Can cause severe adverse effects in non-responders:
  • Systemic hypotension
  • Increased right atrial pressure
  • Decreased cardiac output
  • Right ventricular failure 2
  • Potential death in patients with advanced disease 2

Vasodilators (Including Nitrates)

• Nonselective vasodilators can be dangerous in pulmonary hypertension 3
• Nitroglycerin and other nitrates may cause:
  • Severe systemic hypotension
  • Reflex sympathetic activation (potentially worsening pulmonary pressures)
  • Worsening of right ventricular failure 3
  • Systemic hypoxemia in some patients 3

Serotonergic Drugs with 5-HT2B Receptor Activity

• Fenfluramine and related compounds can cause or worsen pulmonary arterial hypertension 4
• Anorexigens (aminorex, fenfluramine, dexfenfluramine) have strong associations with development of PAH 5
• Selective serotonin reuptake inhibitors may potentially contribute to PAH development 5

Other Medications with Documented Risks

• Dasatinib (tyrosine kinase inhibitor) has strong evidence for causing drug-induced PAH 5
• Interferon alfa has been linked to PAH development, especially in patients with other risk factors 5
• Alkylating agents (bleomycin, cyclophosphamide) can increase risk of pulmonary veno-occlusive disease 5

Clinical Decision Algorithm for Medication Management

1. Assess vasoreactivity status:

   • If positive vasoreactivity test: Consider calcium channel blockers (under careful monitoring)
   • If negative vasoreactivity test or unknown: AVOID calcium channel blockers 1

2. For all patients with pulmonary hypertension:

   • AVOID nonselective vasodilators including nitrates 3
   • AVOID serotonergic drugs with 5-HT2B receptor activity 4
   • AVOID tyrosine kinase inhibitors, particularly dasatinib 5
   • Use extreme caution with any medication that may cause systemic hypotension

3. Preferred medication approaches:

   • For PAH: Consider phosphodiesterase type-5 inhibitors, endothelin receptor antagonists, or soluble guanylate cyclase stimulators 1
   • For right ventricular failure: Consider inotropes rather than fluid boluses 6

Important Monitoring Considerations

• Any medication trial in pulmonary hypertension should be done with direct hemodynamic monitoring 2
• Patients with pulmonary hypertension should be managed at specialized centers with expertise in the condition 2
• Regular echocardiogram assessments are essential when using medications that may affect the pulmonary vasculature 4

Common Pitfalls to Avoid

• Administering calcium channel blockers without confirming vasoreactivity status - this can be fatal 2
• Using nonselective vasodilators that may cause predominant systemic vasodilation 3
• Failing to recognize early signs of medication-induced hemodynamic compromise:
  • Increasing dyspnea
  • Hypotension
  • Rising right atrial pressure
  • Decreasing cardiac output 2
• Attempting fluid boluses in hypotensive patients with right ventricular failure (may worsen condition) 6

Remember that medication management in pulmonary hypertension requires specialized expertise, and patients should ideally be managed at centers with experience in treating this condition.