What is the recommended treatment for hypertension in patients on steroid therapy?

Hypertension Management in Patients on Steroid Therapy

Treat steroid-induced hypertension with standard antihypertensive medications following usual treatment algorithms, as dietary sodium restriction is not indicated for primary prevention of hypertension in patients receiving corticosteroids. 1

Key Principle: Steroids as Blood Pressure Exacerbators

• Corticosteroids are recognized drug exacerbators of hypertension and should be identified during screening of all hypertensive patients. 1
• The hypertensive effect of steroids is highly variable between individuals, with greater increases noted in elderly patients, those with higher baseline blood pressure, or those with kidney disease. 1
• Importantly, hypertension can develop both during maximum corticosteroid use AND paradoxically during steroid dose reduction, particularly in younger patients. 2

Treatment Approach: Standard Antihypertensive Therapy

First-Line Pharmacological Management

Initiate standard antihypertensive medications according to established treatment algorithms, not dietary restriction. 1

• For non-Black patients: Start with low-dose ACE inhibitor or ARB, then add a dihydropyridine calcium channel blocker (DHP-CCB), followed by a thiazide/thiazide-like diuretic if needed. 1, 3
• For Black patients: Start with low-dose ARB plus DHP-CCB or DHP-CCB plus thiazide/thiazide-like diuretic. 1
• Target blood pressure: <130/80 mmHg for most adults if tolerated, or <140/90 mmHg as a minimum threshold. 1, 3, 4

Special Consideration for Steroid-Induced Hypertension

• ACE inhibitors may be particularly effective in steroid-induced hypertension, as elevated renin and aldosterone levels have been documented in patients developing hypertension during corticosteroid therapy. 2
• Hypertension during steroid reduction was resistant to diuretic therapy but responded rapidly to ACE inhibitors in documented cases. 2

Dietary Management: What NOT to Do

Sodium Restriction is NOT Indicated for Prevention

Do not implement prophylactic low-sodium diets in patients starting corticosteroid therapy. 1

• At short-term (≤6 weeks), sodium intake (<3 vs >6 g/day) does not influence blood pressure variations in patients starting systemic corticosteroid therapy. 1
• Salt reduction is not indicated as primary prevention of arterial hypertension in patients with corticosteroid therapy. 1
• The only theoretical indication for salt reduction (but still >6 g sodium chloride/day) is if arterial hypertension actually develops during long-term (>10 weeks) corticosteroid therapy. 1

Standard Hospital Diet is Appropriate

• Patients treated with short-term (≤6 weeks) systemic corticosteroid therapy may receive the standard hospital diet without restriction. 1
• Salt, sugar, fat, or calorie reduction should not be recommended, as the benefit-risk ratio is unfavorable toward a higher risk for malnutrition. 1

Lifestyle Modifications: When Hypertension Develops

If hypertension develops on steroids, implement standard lifestyle interventions as adjunctive therapy, not as primary treatment. 3, 4

• Limit sodium intake to <2.3g sodium per day (approximately <100 mEq/24-hour). 3
• Engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise weekly. 3
• Achieve weight loss if overweight or obese, as weight loss enhances blood pressure lowering, especially with diuretics. 5
• Follow a DASH-type diet rich in whole grains, fruits, vegetables, and polyunsaturated fats. 3, 4
• Limit alcohol intake to <14 units/week for men and <8 units/week for women. 3

Treatment Algorithm for Steroid-Induced Hypertension

Step 1: Confirm Hypertension

• Measure blood pressure in both arms using validated automated upper arm cuff device. 1
• Confirm with home blood pressure monitoring (target <135/85 mmHg) or 24-hour ambulatory monitoring (target <130/80 mmHg). 1

Step 2: Initiate Pharmacological Therapy

• Do not wait for dietary modification alone - start antihypertensive medication if blood pressure is ≥140/90 mmHg sustained. 1
• First choice: ACE inhibitor (given evidence of elevated renin-aldosterone in steroid-induced hypertension). 2
• Alternative: ARB if ACE inhibitor not tolerated. 1, 3

Step 3: Escalate as Needed

• Add DHP-CCB (e.g., amlodipine) if blood pressure not controlled on single agent. 1, 3
• Add thiazide/thiazide-like diuretic as third agent if needed. 1, 3
• Consider spironolactone or other agents for resistant hypertension (≥3 drugs). 3

Step 4: Monitor During Steroid Dose Changes

• Critical pitfall: Blood pressure may paradoxically increase during steroid dose reduction, particularly 1-8 weeks after reduction begins. 2
• Check blood pressure within 4 weeks of any steroid dose adjustment. 3
• Monitor for hypertension at 0-70% of maximum corticosteroid dose during tapering. 2

Common Pitfalls to Avoid

• Do not rely on dietary sodium restriction alone as primary prevention or treatment of steroid-induced hypertension - it is ineffective at short-term and may increase malnutrition risk. 1
• Do not assume hypertension will resolve with steroid discontinuation - it may actually worsen during dose reduction. 2
• Do not use diuretics as first-line monotherapy for steroid-induced hypertension - ACE inhibitors show superior response. 2
• Do not implement unnecessary restrictive diets that cause psychological distress and may worsen nutritional status in patients on long-term corticosteroids. 1
• Do not forget to screen for steroid use when evaluating any patient with hypertension, as it is a common and often overlooked exacerbator. 1