What is the best next step to control hypertension in a patient with tachycardia, palpitations, and a positive blood toxicology screen for amphetamines, who is taking loratadine (antihistamine) pseudoephedrine (sympathomimetic agent) tablets?

Discontinue Oral Decongestant Immediately

The best next step is to discontinue the loratadine-pseudoephedrine combination tablet (Option C), as this patient's hypertension and tachycardia are directly caused by the sympathomimetic effects of pseudoephedrine, compounded by the positive amphetamine screen. 1

Clinical Reasoning

Primary Cause Identification

This patient presents with drug-induced hypertension from two concurrent sympathomimetic agents:

• Pseudoephedrine (oral decongestant) causes systemic vasoconstriction through α-adrenergic receptor stimulation, elevating blood pressure and heart rate 1, 2
• Positive amphetamine screen indicates additional sympathomimetic exposure, which potentiates cardiovascular effects when combined with pseudoephedrine 3
• The 2017 ACC/AHA guidelines explicitly state that "when feasible, drugs associated with increased BP should be reduced or discontinued, and alternative agents should be used" 1

Why Discontinuation is the Correct Answer

The ACC/AHA guidelines specifically recommend discontinuing oral decongestants like pseudoephedrine immediately in patients with acute hypertension and tachycardia, as it represents a reversible cause 2. The guidelines emphasize addressing substance-induced hypertension before initiating antihypertensive medications 1.

Key supporting evidence:

• His baseline blood pressure is 115/60 mmHg with pulse 65/min, indicating this is acute, drug-induced hypertension rather than chronic essential hypertension 2
• The temporal relationship between symptoms (palpitations, dry mouth, urinary frequency after breakfast when likely taking medications) strongly suggests medication-induced sympathomimetic toxicity 1
• Combining amphetamines with pseudoephedrine creates additive vasoconstrictive effects that can lead to hypertensive crisis 2, 3

Why Other Options Are Incorrect

Option A (Reassurance): Inappropriate because this patient has symptomatic hypertension (BP 176/85 mmHg) with tachycardia (106 bpm) caused by identifiable, reversible factors requiring intervention 1

Option B (Continue current treatment): Dangerous because continuing pseudoephedrine with concurrent amphetamine exposure perpetuates the sympathomimetic crisis and risks cardiovascular complications 1, 2, 3

Option D (Initiate ACE inhibitor): Premature because the 2017 ACC/AHA guidelines mandate removing causative agents before starting antihypertensive therapy for drug-induced hypertension 1, 2. This patient lacks end-organ damage requiring immediate pharmacologic intervention 2.

Management Algorithm

Immediate Actions

1. Discontinue loratadine-pseudoephedrine immediately 1, 2
2. Address amphetamine use - determine if prescribed (ADHD medication) or illicit, and discontinue or adjust dosing 1, 3
3. Monitor blood pressure and heart rate - recheck in 24-48 hours after discontinuation to confirm resolution 2

Alternative Therapies for Nasal Congestion

The ACC/AHA guidelines recommend these safer alternatives for hypertensive patients 1, 2:

• Intranasal corticosteroids (most effective and safest long-term option) 1, 2
• Loratadine alone (without pseudoephedrine) - safe antihistamine without blood pressure effects 1, 2
• Nasal saline irrigation - non-pharmacologic option 1, 2
• Topical nasal decongestants (oxymetazoline) - if absolutely necessary, limit to ≤3 days to avoid rhinitis medicamentosa 1, 2

Follow-Up Management

• If blood pressure remains elevated 24-48 hours after discontinuing sympathomimetics, then consider initiating antihypertensive therapy per standard guidelines 2
• Evaluate for underlying secondary hypertension causes if blood pressure does not normalize 1
• The FDA label for amphetamines warns that "caution is to be exercised in prescribing amphetamines for patients with even mild hypertension" 3

Critical Pitfalls to Avoid

Do not start antihypertensive medications before removing the causative agent - this treats the symptom while perpetuating the underlying problem and exposes the patient to unnecessary medication risks 1, 2

Do not overlook the amphetamine-pseudoephedrine interaction - the combination creates synergistic sympathomimetic effects that significantly amplify cardiovascular risks beyond either agent alone 2, 3

Do not use topical decongestants beyond 3 days - this causes rebound congestion (rhinitis medicamentosa) requiring escalating doses 1, 2

Monitor for amphetamine withdrawal symptoms if discontinuing prescribed stimulants, as abrupt cessation may cause dysphoria and fatigue 3