Should I reinstate hypertension medication in a 60-year-old male with a history of hypertension, cocaine, and Adderall (amphetamine and dextroamphetamine) use, who was previously on an unknown antihypertensive medication?

Should You Reinstate Antihypertensive Medication?

Yes, you should absolutely reinstate antihypertensive medication in this 60-year-old male with a history of hypertension, cocaine use, and current Adderall use—but first confirm his current blood pressure is elevated and immediately address the Adderall, which is directly contributing to his hypertension. 1, 2

Immediate Assessment Required

Before prescribing any antihypertensive, you must:

• Measure his blood pressure now to confirm he actually has hypertension requiring treatment (office BP ≥130/80 mmHg) 1
• Obtain repeat measurements on at least 2-3 separate occasions, or ideally confirm with home or ambulatory BP monitoring to rule out white coat hypertension 1
• Screen for cocaine use with urine toxicology, as cocaine causes acute hypertensive crises and cardiovascular complications through powerful vasoconstriction 3
• Assess his Adderall indication and dosing, as amphetamines are a known cause of elevated blood pressure and are specifically listed by the ACC/AHA as medications that cause hypertension 1, 2, 4

Critical Drug-Induced Hypertension Concern

The Adderall is likely a major contributor to his hypertension and must be addressed first:

• Amphetamines like Adderall cause vasoconstriction and increase blood pressure, with 5-15% of patients experiencing substantial BP elevations 2, 4
• The ACC/AHA specifically recommends discontinuing or decreasing the dose of amphetamines in patients with elevated blood pressure 1, 5
• Consider behavioral therapies for ADHD as an alternative to stimulant medication 1
• If Adderall must be continued, use the lowest effective dose and implement more frequent BP monitoring 2, 5

Cocaine history is equally concerning:

• Cocaine causes acute hypertensive crises, myocardial infarction, stroke, and sudden death through powerful vasoconstriction 3
• Even if he reports past use only, verify with toxicology screening as ongoing use would fundamentally change your management approach 3

Choice of Antihypertensive Medication

If his BP remains elevated after addressing stimulant use, initiate antihypertensive therapy with an ACE inhibitor (such as lisinopril 10 mg daily) or an ARB as first-line therapy: 1, 5

Preferred First-Line Options:

• ACE inhibitors (e.g., lisinopril, enalapril) or ARBs (e.g., losartan, valsartan) are appropriate first-line choices for most patients with hypertension 1, 5
• Calcium channel blockers (e.g., amlodipine) are an excellent alternative, particularly if he has a history of cocaine use, as they counteract cocaine-induced vasoconstriction 1, 3
• Thiazide diuretics are also first-line options, especially in elderly patients, though less ideal if he continues stimulant use 1

Critical Medication to AVOID:

• Never use beta-blockers alone in patients with cocaine use or acute cocaine intoxication, as they cause unopposed alpha-adrenergic stimulation leading to paradoxical severe hypertension 3, 6
• If beta-blockers are needed (e.g., for coronary disease), combine with alpha-blockade 3

Monitoring and Follow-Up Algorithm

Establish this systematic approach:

1. Baseline assessment: Obtain current BP (multiple readings), basic metabolic panel (sodium, potassium, creatinine), urinalysis, ECG, and lipid profile 1

2. Target BP: Aim for <130/80 mmHg before continuing or restarting ADHD medication 1, 5

3. Recheck BP after 2-4 weeks of antihypertensive therapy 1, 5

4. If BP remains ≥160/100 mmHg despite treatment: Add a second agent from a different class (e.g., add calcium channel blocker to ACE inhibitor, or add thiazide diuretic) 1, 7

5. Most hypertensive patients require combination therapy to achieve optimal control—be prepared to use 2-3 medications at adequate doses 1, 7

Common Pitfalls to Avoid

• Don't restart antihypertensives blindly without confirming current BP elevation—he may have white coat hypertension or his BP may be normal off medications 1

• Don't ignore medication-induced hypertension—the Adderall is a reversible cause that should be addressed before escalating antihypertensive therapy 1, 2

• Don't use inadequate doses—most patients need full therapeutic doses or combination therapy to achieve BP control 7

• Don't use beta-blockers as monotherapy in anyone with potential cocaine use 3, 6

• Don't forget to assess adherence—poor adherence is the most common cause of apparent treatment resistance, affecting 40% of patients in the first year 1

• Don't overlook secondary causes—at age 60 with a history of substance abuse, screen for renal disease (creatinine, urinalysis) and consider sleep apnea if he has obesity or snoring 1