What is the best next step to control hypertension in a patient with elevated blood pressure and tachycardia, currently taking loratadine-pseudoephedrine (pseudoephedrine) and with a positive blood toxicology screen for amphetamine?

Discontinue Pseudoephedrine Immediately

The best next step is to discontinue the oral decongestant (pseudoephedrine) immediately, as this is the most likely reversible cause of this patient's acute hypertension and tachycardia. 1

Clinical Reasoning

This patient presents with acute-onset hypertension (176/85 mmHg vs baseline 115/60 mmHg) and tachycardia (106 bpm vs baseline 65 bpm) that temporally correlates with his use of loratadine-pseudoephedrine for nasal congestion. The positive amphetamine screen is explained by pseudoephedrine's structural similarity to amphetamines, causing false-positive results on standard toxicology screens. 1

Key Evidence Supporting Pseudoephedrine as the Culprit

• The 2017 ACC/AHA guidelines explicitly identify decongestants (pseudoephedrine, phenylephrine) as substances that may cause elevated blood pressure and recommend considering alternative therapies such as nasal saline, intranasal corticosteroids, or antihistamines. 1

• The American Academy of Allergy, Asthma, and Immunology notes that pseudoephedrine works as an α-adrenergic agonist causing systemic vasoconstriction, which explains its potential to elevate blood pressure and heart rate. 2

• Meta-analysis data demonstrates pseudoephedrine increases systolic blood pressure by 0.99 mmHg and heart rate by 2.83 beats/min in normotensive individuals, but individual responses vary significantly. 2, 3

Why Not Start Antihypertensive Medication?

Starting an ACE inhibitor (Option D) would be premature and inappropriate before addressing the iatrogenic cause. 1 The guidelines emphasize that when feasible, drugs associated with increased blood pressure should be reduced or discontinued, and alternative agents should be used first. 1

This patient does not have true essential hypertension requiring chronic pharmacotherapy—he has drug-induced hypertension from a sympathomimetic agent. 1 His baseline blood pressure of 115/60 mmHg confirms he was normotensive before starting pseudoephedrine. 1

Clinical Pitfalls to Avoid

Do not mistake pseudoephedrine-induced hypertension for a hypertensive emergency requiring immediate pharmacologic intervention. 1 While his blood pressure is elevated at 176/85 mmHg, he lacks signs of end-organ damage (normal chest X-ray, ECG shows only sinus tachycardia, no cardiac murmurs, adequate lung fields). 1

The positive amphetamine screen should not trigger a substance abuse workup in this context. 1 Pseudoephedrine causes false-positive amphetamine results on standard immunoassay drug screens due to structural similarity. The clinical presentation (nasal congestion, rhinitis symptoms, eosinophilia at 18.4%) supports allergic rhinitis being treated with over-the-counter decongestants rather than illicit drug use. 2

Recommended Management Algorithm

1. Immediately discontinue loratadine-pseudoephedrine 1

2. Substitute with safer alternatives for nasal congestion: 1

   • Intranasal corticosteroids (first-line for chronic rhinitis) 1, 2
   • Antihistamines alone (loratadine without pseudoephedrine) 1
   • Nasal saline irrigation 1
   • Short-term topical decongestants (≤3 days only) if absolutely necessary 2, 4

3. Recheck blood pressure in 24-48 hours after pseudoephedrine discontinuation to confirm resolution 1

4. If blood pressure remains elevated (≥140/90 mmHg) after 2-3 office visits following pseudoephedrine discontinuation, then consider initiating antihypertensive therapy per standard guidelines 1

Expected Clinical Course

Blood pressure and heart rate should normalize within 24-48 hours after discontinuing pseudoephedrine, given its half-life of 5-8 hours. 2 The sympathomimetic effects resolve quickly once the drug is cleared. 3

Why Reassurance Alone (Option A) Is Insufficient

While the hypertension is likely drug-induced and reversible, simply reassuring the patient without stopping the causative agent would be negligent. 1 The guidelines explicitly state that drugs associated with increased blood pressure should be discontinued when feasible. 1

Why Continuing Current Treatment (Option B) Is Contraindicated

Continuing pseudoephedrine in a patient with acute hypertension and tachycardia directly contradicts guideline recommendations. 1, 5 The FDA drug label for pseudoephedrine warns to "ask a doctor before use if you have high blood pressure" and to "stop use and ask a doctor if nervousness, dizziness, or sleeplessness occur." 5 This patient meets criteria for discontinuation. 5

Patients with uncontrolled hypertension should avoid pseudoephedrine if possible, and if decongestant therapy is necessary, topical nasal decongestants for short-term use under medical supervision are a safer alternative. 2, 4