Which antihypertensive medication contributes to gum bleeding?

Calcium Channel Blockers Are the Primary Antihypertensive Class Associated with Gum Bleeding

Calcium channel blockers, particularly dihydropyridines like amlodipine and nifedipine, are the antihypertensive medications most strongly associated with gingival bleeding and gum hypertrophy. 1

Mechanism and Clinical Presentation

• Cyclosporine (though not an antihypertensive) provides the clearest evidence of this drug class effect, causing gum hypertrophy and bleeding as a frequent adverse effect that reverses upon drug discontinuation 1
• Calcium channel blockers cause gingival overgrowth through altered collagen metabolism and fibroblast proliferation in gum tissue, which predisposes to bleeding 1
• The gingival changes typically manifest as hypertrophy, hyperplasia, and increased bleeding tendency during routine oral hygiene 1

Specific Calcium Channel Blockers Implicated

• Amlodipine and nifedipine (dihydropyridines) are the most commonly prescribed calcium channel blockers that can cause gingival bleeding 1
• These medications are widely used as first-line or add-on therapy for hypertension, making this adverse effect clinically relevant 1

Other Antihypertensive Medications Associated with Gum Bleeding

ACE Inhibitors

• Enalapril and ramipril have been identified as drugs "not usually known to be involved in bleeding" but were found in pharmacovigilance data to be associated with gingival bleeding 2
• The mechanism may involve bradykinin accumulation (which ACE normally degrades), leading to increased vascular permeability and bleeding tendency 2, 3
• ACE inhibitors may worsen periodontal disease, with patients showing 3.2-fold higher risk of pocket depth ≥5 mm and 2.9-fold higher risk of clinical attachment loss ≥5 mm, which could contribute to bleeding 3

Loop Diuretics

• Furosemide was the second most frequently suspected drug after antithrombotics in causing gingival bleeding in French pharmacovigilance data 2
• The mechanism is unclear but may relate to electrolyte disturbances or vascular effects 2

Important Clinical Caveats

• Most reported cases of drug-induced gingival bleeding (58.4%) were classified as "serious" adverse reactions, indicating this is not merely a cosmetic concern 2
• Patients older than 50 years and women are at particularly higher risk for antihypertensive-related gingival bleeding 2
• The frequency of gingival bleeding increases with age in patients taking antihypertensive medications 2

Differential Considerations

• Beta-blockers (atenolol, metoprolol, propranolol) and centrally-acting agents (clonidine) affect oral microcirculation but are not primarily associated with gingival bleeding 1, 4
• Antithrombotic drugs remain the most common cause of gingival bleeding overall (67.8% of cases), but among pure antihypertensives, calcium channel blockers are the primary culprits 2

Management Approach

• If gingival bleeding develops in a patient on calcium channel blockers, consider switching to an alternative antihypertensive class such as ACE inhibitors, ARBs, or beta-blockers 1
• Maintain meticulous oral hygiene as gingival hyperplasia from calcium channel blockers worsens with poor dental care 1
• The gingival changes are typically reversible upon drug discontinuation, though this must be balanced against blood pressure control needs 1