Should Terazosin be held in a patient with hypotension?

Should Terazosin Be Held for Blood Pressure 122/57?

No, terazosin should not be held for a blood pressure of 122/57 mmHg, as this reading does not represent clinically significant hypotension that would warrant withholding the medication. 1

Blood Pressure Threshold for Clinical Concern

• The blood pressure reading of 122/57 mmHg is not considered severe hypotension requiring intervention 2
• Severe hypotension requiring vasopressor support is typically defined as systolic blood pressure ≤70 mmHg, which is far below the presented value 2
• The FDA label for terazosin warns about marked lowering of blood pressure and postural hypotension, but does not specify holding the medication at normotensive readings 1

Key Clinical Considerations

Symptomatic vs. Asymptomatic Hypotension

• The critical decision point is whether the patient is experiencing symptoms of hypotension (dizziness, lightheadedness, syncope, weakness) rather than the absolute blood pressure number alone 1
• If the patient is asymptomatic with BP 122/57, terazosin can be safely continued 1, 3
• If symptomatic hypotension or syncope occurs, the patient should be placed in a recumbent position and terazosin should be held until symptoms resolve 1

Orthostatic Hypotension Assessment

• Before deciding to hold terazosin, perform orthostatic vital signs to assess for postural hypotension 1, 4
• Measure blood pressure supine and after standing for 1-3 minutes 1
• A drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg with symptoms indicates clinically significant orthostatic hypotension 1
• In clinical trials of terazosin for BPH, the incidence of postural hypotension ranged from 3.7-5.2%, and these patients required intervention 2

Risk Factors for Terazosin-Induced Hypotension

Timing Considerations

• The risk of hypotensive events is greatest during the initial 7 days of treatment and within 90 minutes of dosing 1
• The orthostatic effect of terazosin is greater shortly after dosing, even in chronic use 1
• If this is a chronic user on stable dosing, the BP of 122/57 is less concerning than if this occurred within the first week of therapy 1

High-Risk Scenarios Requiring Caution

• First dose or first few days of therapy 1
• Recent dose escalation 1
• Therapy interrupted for several days and then restarted 1
• Concurrent use of other antihypertensive agents 1
• Volume depletion or dehydration (hemodilution can contribute to postural hypotension) 1

Management Algorithm

If Patient is Asymptomatic with BP 122/57:

1. Continue terazosin as prescribed 3
2. Ensure the patient is taking the medication at bedtime to minimize orthostatic effects 1
3. Counsel patient to avoid situations where syncope could cause injury (driving, operating machinery) if they develop symptoms 1
4. Advise patient to rise slowly from sitting or lying positions 1

If Patient Has Symptoms (Dizziness, Lightheadedness):

1. Hold the current dose and place patient in recumbent position 1
2. Assess for orthostatic hypotension with vital signs 1
3. Evaluate for volume depletion and provide supportive care 1
4. Consider dose reduction when restarting, as terazosin should be titrated slowly 1
5. If severe hypotension develops, treat with volume expanders first, then vasopressors if necessary 1

Evidence from Clinical Trials

• In normotensive patients with BPH treated with terazosin, there were no clinically significant mean changes in systolic or diastolic blood pressure during treatment 3
• In controlled hypertensive patients already on antihypertensive medications, terazosin did not adversely affect blood pressure control 3
• Among nearly 2,000 hypertensive patients treated with terazosin in multiple dose trials, syncope occurred in only about 1% of patients 1

Common Pitfalls to Avoid

• Do not reflexively hold terazosin based solely on a diastolic BP in the 50s without assessing for symptoms 3
• Do not restart terazosin at the previous dose if therapy has been interrupted for several days; restart at 1 mg and retitrate 1
• Do not ignore the contribution of concurrent medications or volume status to hypotension 1
• Remember that terazosin is 90-94% protein bound, so dialysis is not beneficial in overdose situations 1