Cold Medication for Patients with Hypertension
For patients with hypertension who have a cold, acetaminophen (paracetamol) is the safest option for symptom relief, but should be used at the lowest effective dose for the shortest duration, while avoiding all sympathomimetic decongestants (pseudoephedrine, phenylephrine, phenylpropanolamine) which can significantly elevate blood pressure. 1
Medications to AVOID
Sympathomimetic decongestants are contraindicated in hypertensive patients:
Pseudoephedrine, phenylephrine, and phenylpropanolamine all stimulate alpha-adrenergic receptors and can elevate blood pressure, with effects that are highly variable and potentially greater in elderly patients, those with higher baseline BP, or those already on antihypertensive therapy 1, 2
These agents are explicitly listed in the 2020 International Society of Hypertension guidelines as substances that may increase BP or antagonize antihypertensive therapy 1
The 2017 ACC/AHA guidelines recommend using decongestants for the shortest duration possible and avoiding them entirely in severe or uncontrolled hypertension 1
Safe Medication Options
Acetaminophen (with important caveats):
Acetaminophen may help relieve nasal obstruction and rhinorrhea in adults with colds 3
Critical warning: Regular acetaminophen use (4g daily) increases systolic BP by approximately 5 mmHg in hypertensive patients, which translates to increased cardiovascular risk 4
The 2020 ISH guidelines note an increased relative risk of 1.34 for hypertension with almost daily acetaminophen use 1
Recommendation: Use acetaminophen only as needed (not regularly), at the lowest effective dose (≤2g daily rather than 4g), and for the shortest duration possible 4
Alternative symptom-specific treatments:
For nasal congestion: Topical (intranasal) saline irrigation is safe and effective without BP effects 5
For rhinorrhea: Topical ipratropium (prescription anticholinergic) relieves nasal symptoms without affecting blood pressure 5
For cough: Dextromethorphan may provide modest benefit in adults without BP effects 5
Antihistamines: First-generation antihistamines (diphenhydramine, chlorpheniramine) can modestly improve symptoms but cause sedation; newer nonsedating antihistamines are ineffective for cold symptoms 5
Monitoring Considerations
Patients should monitor their blood pressure more frequently during cold medication use, particularly if using acetaminophen regularly 4
If BP rises significantly (>10 mmHg systolic), discontinue the cold medication and contact their healthcare provider 1
The BP-elevating effects are more pronounced in elderly patients, those with higher baseline BP, and those already on antihypertensive therapy 1
Non-Pharmacologic Approaches
These are safe and may provide additive benefit without BP concerns:
Humidified air and adequate fluid intake 5
Rest and supportive care 5
Vitamin C supplementation may modestly reduce symptom duration and severity 5
Common Pitfall to Avoid
Do not use combination cold preparations without carefully checking all ingredients, as most contain sympathomimetic decongestants (pseudoephedrine or phenylephrine) that are contraindicated in hypertension 1, 2. Even products marketed as "non-drowsy" typically contain these problematic decongestants.