What are the guidelines for withholding antihypertensive (blood pressure lowering) medications?

From the Guidelines

Antihypertensive medications should be withheld in patients with systolic blood pressure below 90 mmHg or diastolic blood pressure below 60 mmHg, or if the patient shows signs of hypoperfusion such as dizziness, confusion, or syncope, as recommended by the 2020 international society of hypertension global hypertension practice guidelines 1. When considering withholding antihypertensive medications, it is essential to evaluate the patient's overall clinical condition and potential risks associated with uncontrolled hypertension.

• Withhold antihypertensive medications during acute illnesses with volume depletion (vomiting, diarrhea, fever) to prevent further hypotension and organ hypoperfusion.
• Hold ACE inhibitors, ARBs, and diuretics 24 hours before surgical procedures to minimize the risk of perioperative hypotension, as suggested by the 2018 American College of Cardiology/American Heart Association hypertension guideline 1.
• In cases of acute kidney injury, especially with ACE inhibitors, ARBs, and diuretics, withhold these medications to prevent further renal deterioration. For specific medications:
• ACE inhibitors and ARBs should be withheld with potassium levels above 5.0 mEq/L or creatinine elevation >30% from baseline to avoid hyperkalemia and worsening renal function.
• Beta-blockers should not be abruptly discontinued due to rebound hypertension risk but should be withheld with heart rate below 50 beats per minute or during bronchospasm to prevent adverse cardiac effects.
• Diuretics should be withheld with electrolyte abnormalities (potassium <3.5 mEq/L) or significant dehydration to prevent further electrolyte imbalances and hypovolemia. When restarting medications after withholding, begin at lower doses and titrate gradually while monitoring blood pressure, heart rate, and relevant laboratory values to minimize the risk of adverse events. These guidelines help prevent adverse events like hypotension, syncope, electrolyte disturbances, and organ hypoperfusion while maintaining long-term blood pressure control, ultimately reducing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

If hypotension occurs (systolic blood pressure ≤ 100 mmHg) a daily maintenance dose of 5 mg may be given with temporary reductions to 2. 5 mg if needed. If prolonged hypotension occurs (systolic blood pressure < 90 mmHg for more than 1 hour) lisinopril tablets should be withdrawn.

Withholding antihypertensive medication should be considered in the following situations:

• Hypotension: If systolic blood pressure is ≤ 100 mmHg, the dose may be temporarily reduced to 2.5 mg.
• Prolonged hypotension: If systolic blood pressure is < 90 mmHg for more than 1 hour, lisinopril tablets should be withdrawn. 2

From the Research

Guidelines for Withholding Antihypertensive Medication

• The decision to withhold antihypertensive medication should be made on a case-by-case basis, taking into account the individual patient's medical history and current health status 3.
• Temporary discontinuation of antihypertensive medication may be necessary for diagnostic evaluations, but it should be done in a well-controlled setting with appropriate protocols for monitoring safety 3.
• The risk of adverse cardiovascular and cerebrovascular events associated with withholding antihypertensive medication is low when performed in a controlled setting 3.
• Patients with difficult-to-control hypertension may require closer monitoring when withholding antihypertensive medication 3.

Considerations for Specific Patient Populations

• Older patients undergoing non-cardiac surgery may benefit from continuing angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) perioperatively, as withholding these medications may increase the risk of perioperative hypotension and postoperative complications 4.
• Patients with hypertension and comorbidities such as arteriosclerosis obliterans may require individualized treatment plans, including the use of combination therapy with lisinopril and amlodipine 5.

Monitoring and Follow-up

• Patients who have their antihypertensive medication withheld should be closely monitored for signs of hypertension, cardiovascular disease, and other potential complications 3, 4.
• Regular follow-up appointments should be scheduled to assess the patient's response to treatment and adjust the treatment plan as needed 5, 6.

Treatment Options

• Various antihypertensive medications, including lisinopril, losartan, and amlodipine, have been shown to be effective in reducing blood pressure and improving cardiovascular outcomes 5, 6, 7.
• The choice of antihypertensive medication should be based on the individual patient's medical history, current health status, and potential side effects 7.