What over-the-counter (OTC) drugs should be avoided if you have hypertension?

OTC Drugs to Avoid if You Have Hypertension

If you have hypertension, avoid NSAIDs (ibuprofen, naproxen), decongestants (pseudoephedrine, phenylephrine), and limit caffeine and alcohol intake, as these are the primary over-the-counter culprits that can elevate blood pressure and interfere with your antihypertensive medications. 1

Primary OTC Medications to Avoid

NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)

• NSAIDs can increase blood pressure by 3-6 mm Hg in patients with controlled hypertension, with effects appearing within the first weeks of treatment. 1
• Common NSAIDs to avoid include ibuprofen, naproxen, and aspirin (when used regularly at high doses). 2, 3, 4
• NSAIDs directly antagonize the blood pressure-lowering effects of ACE inhibitors, ARBs, diuretics, and beta-blockers—meaning they work against your blood pressure medications. 1
• Alternative pain relievers: Use acetaminophen (in moderation), tramadol, or topical NSAIDs instead of oral NSAIDs when possible. 1
• Important caveat: Even acetaminophen is not completely safe—regular use increases the relative risk of hypertension by 1.34, so use it judiciously. 1

Decongestants

• Pseudoephedrine and phenylephrine are sympathomimetic agents that directly raise blood pressure through vasoconstriction. 2, 1
• These are found in cold and sinus medications (Sudafed, many multi-symptom cold formulas). 2
• Use decongestants for the shortest duration possible and avoid them entirely in severe or uncontrolled hypertension. 1
• Safe alternatives: Nasal saline rinses, intranasal corticosteroids (Flonase), or antihistamines (which do not raise blood pressure). 2
• Guaifenesin-only products (plain Mucinex) are safe for hypertensive patients—just verify the product contains only guaifenesin and no decongestants. 5

Caffeine

• Limit caffeine intake to less than 300 mg daily (approximately 3 cups of coffee). 1
• Avoid caffeine entirely if you have uncontrolled hypertension. 1
• Coffee causes acute increases in blood pressure, though long-term use is not associated with sustained hypertension or cardiovascular disease. 2

Alcohol

• Limit alcohol to ≤1 drink daily for women and ≤2 drinks daily for men. 2, 1
• Excessive alcohol consumption is a well-established cause of elevated blood pressure. 2

Herbal Supplements and Other Substances to Avoid

High-Risk Herbal Products

• Avoid Ma Huang (ephedra), yohimbine, St. John's wort, ginseng, and licorice—all can increase blood pressure. 1
• These products are not regulated by the FDA and can have unpredictable effects on blood pressure. 1

Clinical Management Algorithm

Step 1: Screen All OTC Medications

• Take a careful history of all prescription medications, OTC substances, illicit drugs, and herbal products at every visit. 1
• Many patients do not consider OTC medications "real drugs" and fail to report them unless specifically asked. 1

Step 2: Discontinue or Reduce Problematic Agents

• When feasible, reduce or discontinue drugs associated with increased blood pressure and use alternative agents. 1
• For NSAIDs: Switch to acetaminophen (limited use), tramadol, or topical NSAIDs. 2, 1
• For decongestants: Switch to nasal saline, intranasal corticosteroids, or antihistamines. 2

Step 3: Monitor Blood Pressure Closely

• Monitor blood pressure closely during initiation of any new OTC medication or supplement, especially in the first weeks of treatment. 1
• This is critical because blood pressure effects can appear rapidly (within days to weeks). 1

Step 4: Adjust Antihypertensive Therapy if Needed

• If the problematic OTC medication cannot be discontinued (e.g., chronic pain requiring NSAIDs), consider intensifying antihypertensive therapy to compensate. 2
• However, discontinuation of the offending agent is always preferable to adding more blood pressure medications. 1

Common Pitfalls to Avoid

• Do not assume "natural" or "herbal" means safe—many herbal supplements significantly raise blood pressure. 1
• Read labels carefully on combination cold medications—many contain both a decongestant (problematic) and guaifenesin (safe). 5
• Do not use immediate-release nifedipine for hypertensive urgencies—it causes unpredictable blood pressure drops and is associated with adverse outcomes. 6, 7
• Be aware that NSAIDs can blunt the effectiveness of diuretics, leading to fluid retention and worsening blood pressure control. 4, 8