Can a patient scheduled for upper and lower endoscopy (EGD and colonoscopy) take their regular anti-hypertensive medication on the day of the procedure?

Management of Antihypertensive Medications for Endoscopy Procedures

Patients scheduled for upper and lower endoscopy (EGD and colonoscopy) should continue their regular antihypertensive medications on the day of the procedure, including the morning of surgery.

Evidence-Based Recommendations

General Approach to Antihypertensive Medications Before Endoscopy

• The American College of Cardiology/American Heart Association (ACC/AHA) guidelines clearly recommend continuing medical therapy for hypertension until surgery for patients undergoing planned elective procedures 1.
• For patients who have been on beta-blockers chronically, these medications should absolutely be continued through the perioperative period (Class I, Level B-NR recommendation) 1.
• Continuing antihypertensive medications helps maintain hemodynamic stability and reduces the risk of blood pressure fluctuations during and after the procedure.

Medication-Specific Recommendations

1. Beta-blockers:

   • Must be continued without interruption (Class I recommendation) 1
   • Abrupt discontinuation can cause dangerous rebound hypertension and tachycardia (Class III: Harm) 1

2. Calcium channel blockers:

   • Should be continued through the perioperative period 2
   • Associated with improved hemodynamic stability during procedures

3. ACE inhibitors/ARBs:

   • May be considered for discontinuation 24 hours before major surgery (Class IIb recommendation) 1, 2
   • However, for low-risk procedures like endoscopy, the evidence from a prospective study specifically examining colonoscopy showed no increased risk of procedural hypotension with continued use of antihypertensive medications 3

4. Diuretics:

   • Consider holding on the day of procedure due to potential dehydration concerns from bowel preparation 2
   • Can be resumed post-procedure once oral intake is established

5. Alpha-2 agonists (e.g., clonidine):

   • Must be continued without interruption
   • Abrupt discontinuation can cause dangerous rebound hypertension (Class III: Harm) 1

Special Considerations for Endoscopy

Endoscopy procedures (EGD and colonoscopy) are considered low-risk procedures compared to major surgery, which influences medication management:

• A prospective study specifically examining patients undergoing colonoscopy found that taking antihypertensive medications, regardless of class, was not associated with an increased risk of procedural hypotension 3.

• The main risk factor for hypotension during colonoscopy was actually lower pre-procedure blood pressure, not medication use 3.

• Continuing antihypertensive medications is associated with lower 90-day mortality among hypertensive patients undergoing procedures 4.

Potential Pitfalls and Caveats

• Dehydration risk: Patients undergoing colonoscopy may be relatively dehydrated from bowel preparation, which could theoretically potentiate hypotension with certain medications. Ensure adequate hydration before and during the procedure.

• Medication timing: For morning procedures, patients should take their medications with a small sip of water as early as possible before the procedure.

• Blood pressure monitoring: More frequent blood pressure monitoring during the procedure may be warranted for patients with poorly controlled hypertension or those on multiple antihypertensive medications.

• Grade 3 hypertension: For patients with severe hypertension (systolic ≥180 mmHg or diastolic ≥110 mmHg), consider postponing elective procedures until better blood pressure control is achieved 1, 2.

Conclusion

The evidence strongly supports continuing regular antihypertensive medications for patients undergoing endoscopy procedures. This approach maintains cardiovascular stability, prevents rebound hypertension, and is associated with better outcomes. The only potential exception might be ACE inhibitors/ARBs, which some guidelines suggest could be held on the day of major surgery, but for low-risk endoscopy procedures, continuing these medications appears safe based on available evidence.