What over-the-counter (OTC) medications can increase blood pressure (hypertension)?

Over-the-Counter Medications That Can Increase Blood Pressure

The most common OTC medications that increase blood pressure are NSAIDs (ibuprofen, naproxen), decongestants (pseudoephedrine, phenylephrine), caffeine in high doses, and acetaminophen with regular use. 1

Primary OTC Culprits

NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)

• NSAIDs can increase blood pressure by 3-6 mm Hg in patients with controlled hypertension, with effects potentially appearing within the first weeks of treatment 1, 2, 3
• Common OTC NSAIDs include ibuprofen (Advil, Motrin) and naproxen (Aleve) 4, 2
• NSAIDs antagonize the blood pressure-lowering effects of multiple antihypertensive classes, including ACE inhibitors, ARBs, diuretics, and beta-blockers 1, 4
• The mechanism involves inhibition of prostaglandin synthesis, which normally promotes vasodilation and sodium excretion 2, 3
• Avoid systemic NSAIDs when possible; consider alternative analgesics such as acetaminophen, tramadol, or topical NSAIDs 1

Decongestants

• Pseudoephedrine and phenylephrine are sympathomimetic agents that directly raise blood pressure 1
• These are found in cold and sinus medications (Sudafed, many multi-symptom cold preparations) 1
• Use for the shortest duration possible and avoid entirely in severe or uncontrolled hypertension 1
• Consider alternative therapies including nasal saline, intranasal corticosteroids, or antihistamines 1

Acetaminophen (Tylenol)

• Regular acetaminophen use (almost daily) increases the relative risk of hypertension by 1.34 1, 5
• In patients with existing hypertension, regular dosing of 4 grams daily increases systolic BP by approximately 5 mm Hg 6, 5
• The blood pressure-raising effect is dose-dependent and more pronounced in elderly patients, those with higher baseline BP, patients on antihypertensive therapy, and those with kidney disease 1, 5
• Despite these effects, acetaminophen may still be preferable to NSAIDs in patients with resistant hypertension, but blood pressure should be monitored closely 5

Caffeine

• Limit caffeine intake to less than 300 mg daily (approximately 3 cups of coffee) 1
• Avoid caffeine use in patients with uncontrolled hypertension 1
• Coffee causes acute increases in BP, but long-term use is not associated with sustained BP elevation or increased cardiovascular disease 1

Herbal Supplements and Other OTC Substances

High-Risk Herbal Products

• Ma Huang (ephedra), yohimbine, St. John's wort (when combined with MAO inhibitors), ginseng at high doses, and liquorice should be avoided 1, 7
• Herbal supplements have "high" potential to increase blood pressure and should be screened for in all hypertensive patients 7
• Supplements marketed for athletic performance or sexual enhancement often contain stimulants that affect blood pressure 7

Alcohol

• Limit alcohol to ≤1 drink daily for women and ≤2 drinks daily for men 1

Clinical Management Algorithm

Screening Approach

1. Screen ALL patients with hypertension or at risk for hypertension for OTC medications, supplements, and substances that may increase BP 1, 7
2. Pay particular attention to elderly patients, those with pre-existing hypertension, patients on antihypertensive therapy, and those with kidney disease—these groups show greater BP increases 1, 5, 8
3. Take a careful history including prescription medications, OTC substances, illicit drugs, and herbal products 1

Management Strategy

1. When feasible, reduce or discontinue drugs associated with increased BP and use alternative agents 1
2. If the offending agent is required or preferred, treat BP to target regardless 1, 5
3. Monitor blood pressure closely during initiation of any new OTC medication or supplement, especially in the first weeks of treatment 7, 4, 2
4. Consider non-pharmacological alternatives when appropriate (e.g., nasal saline for congestion, topical NSAIDs for localized pain) 1

Important Clinical Caveats

• Individual responses to these substances are highly variable based on genetics, existing medical conditions, and concurrent medications 7, 8
• The effect of these medications on BP can vary significantly between individuals, with some experiencing minimal changes and others showing substantial increases 1, 8
• Even short-term NSAID therapy carries cardiovascular risk, not just chronic use 4, 3
• An estimated 20 million patients and 12% of the population aged ≥60 years take concurrent NSAIDs and antihypertensive medication, making this interaction extremely common 2
• Small increases in BP (3-6 mm Hg) can produce significant increases in subsequent stroke, end-stage renal disease, or congestive heart failure, particularly in elderly patients 2, 3