Can I skip medications for anemia and hypertension if I have hypotension?

Managing Hypertension Medications During Anemia and Low Blood Pressure

For patients with anemia and hypertension who are experiencing low blood pressure, medications should be temporarily stopped until symptoms resolve and normal eating and drinking resume, especially if the patient is symptomatic.

Assessment of Low Blood Pressure in Anemic Hypertensive Patients

When to Consider Medication Adjustment

• Symptomatic hypotension (dizziness, lightheadedness, fatigue)
• Systolic BP <80 mmHg 1
• Orthostatic hypotension (decrease in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg within 3 minutes of standing) 2
• Signs of inadequate organ perfusion

Relationship Between Anemia and Blood Pressure

• Anemia can cause compensatory vasodilation and reduced vascular resistance due to:
  • Lower blood viscosity
  • Hypoxia-induced vasodilation
  • Enhanced nitric oxide activity 3
• Normocytic anemia is highly prevalent in hypertensive patients (16%) and is associated with poor BP control 4
• Iron deficiency anemia combined with zinc deficiency can lead to decreased aldosterone levels and hypotension 5

Medication Management Algorithm

Step 1: Medications to Temporarily Stop (for up to 3 days)

1. Volume-depleting medications:

   • Loop diuretics (e.g., furosemide) 1
   • Thiazide/thiazide-like diuretics 1
   • Potassium-sparing diuretics 1

2. Vasodilators and BP-lowering agents:

   • ACE inhibitors/ARBs 1
   • ARNI (sacubitril/valsartan) 1
   • SGLT2 inhibitors 1

3. Other medications to consider holding:

   • NSAIDs 1
   • If blood glucose is low: insulin/sulfonylurea/meglitinide 1

Step 2: Monitoring During Medication Hold

• Check BP regularly (both lying and standing)
• Monitor for symptoms of hypotension
• Ensure adequate hydration
• For diabetic patients: monitor blood glucose every 4-6 hours while awake 1

Step 3: Resuming Medications

• Resume medications at usual doses within 24-48 hours of eating and drinking normally 1
• For volume-depleting medications: resume at usual doses after 24-48 hours of normal eating and drinking 1
• For medications that can cause hypoglycemia: resume at usual doses as soon as symptoms improve and normal eating/drinking resume 1

Special Considerations

For Anemia Management

• Identify and treat the underlying cause of anemia
• Consider vitamin B12 deficiency as a potential cause, especially if orthostatic hypotension is present 6
• Monitor hemoglobin levels, as antihypertensive medications (especially ACE inhibitors and ARBs) can reduce hemoglobin concentration 7

For Orthostatic Hypotension

• Acute water ingestion (≥240-480 mL) for temporary relief 2
• Increase fluid intake to 2-2.5L daily 2
• Moderate salt intake if not contraindicated 2
• Isometric exercises (leg crossing, lower body muscle tensing) 2
• Compression garments 2
• Elevate head of bed 10-20° during sleep 2

When to Seek Medical Attention

Contact Healthcare Provider When:

• Symptoms last >72 hours 1
• Significant increase in blood glucose not improving with self-adjustment after 24 hours 1
• Recurrent low blood glucose readings 1

Seek Emergency Care For:

• Difficulty or rapid breathing 1
• Reduced level of consciousness or new confusion 1
• Fainting or falls 1

Long-term Management Principles

Treatment Goals

• The goal is to minimize orthostatic symptoms and improve standing time for activities of daily living, not to normalize blood pressure 2
• Asymptomatic or mildly symptomatic low BP should not be a reason for complete discontinuation of guideline-directed medical therapy 1
• When BP improves, always consider reinitiation or rechallenge of drugs based on better tolerated first 1

Medication Selection for Hypertension with Anemia

• SGLT2 inhibitors and mineralocorticoid receptor antagonists (MRAs) have the least effect on BP and may actually increase BP in low BP groups 1
• When discontinuation or reduction of therapy is needed, start with the less tolerated medications 1

By following this approach, you can safely manage hypertension medications during periods of anemia and low blood pressure while minimizing risks and optimizing patient outcomes.