Can over-the-counter (OTC) cough medications, particularly those containing pseudoephedrine or phenylephrine, acutely increase blood pressure in patients with pre-existing hypertension or cardiovascular conditions?

Do OTC Cough Medications Actually Acutely Increase Blood Pressure?

Yes, OTC cough medications containing decongestants (pseudoephedrine and phenylephrine) do acutely increase blood pressure, but the magnitude is generally small in most patients—approximately 1 mmHg systolic—and becomes clinically significant primarily in patients with uncontrolled hypertension or specific cardiovascular conditions. 1

Magnitude of Blood Pressure Effects

Pseudoephedrine

• Meta-analysis demonstrates that pseudoephedrine increases systolic blood pressure by 0.99 mmHg (95% CI, 0.08-1.90) and heart rate by 2.83 beats/min (95% CI, 2.0-3.6), with no significant effect on diastolic blood pressure (0.63 mmHg; 95% CI, –0.10 to 1.35) in the general population 1
• In patients with controlled hypertension, pseudoephedrine at standard doses shows no statistically significant or clinically important differences in mean systolic or diastolic blood pressures 2
• The American Academy of Allergy, Asthma, and Immunology notes the effect is generally small in most patients but clinically significant in those with uncontrolled hypertension 1

Phenylephrine

• Phenylephrine works as an α-adrenergic agonist causing systemic vasoconstriction, which directly raises blood pressure 1
• The FDA label warns that phenylephrine can cause hypertensive crisis as an adverse reaction 3
• Oral phenylephrine formulations are less effective than pseudoephedrine due to extensive first-pass metabolism, with questionable efficacy as oral decongestants 1

Mechanism of Action

• Pseudoephedrine stimulates both alpha and beta receptors, elevating blood pressure with an increase or no change in heart rate 4
• Phenylephrine stimulates alpha-adrenergic receptors exclusively, causing elevation of blood pressure and a reflex decrease in heart rate 4
• Both agents cause systemic vasoconstriction through sympathomimetic activity 5

Clinical Risk Stratification

Patients with Controlled Hypertension

• The American College of Cardiology states that patients with controlled hypertension can generally use pseudoephedrine safely at standard doses, though blood pressure monitoring is recommended due to interindividual variation 1
• A 4-week randomized controlled trial found no significant changes in blood pressure in patients with controlled hypertension taking pseudoephedrine 2

Patients with Uncontrolled or Severe Hypertension

• The American Heart Association advises using decongestants for the shortest duration possible and avoiding them entirely in severe or uncontrolled hypertension 5
• The American College of Cardiology recommends that decongestants should be avoided in patients with severe or uncontrolled hypertension 1
• Patients with uncontrolled hypertension should avoid pseudoephedrine if possible; if decongestant therapy is necessary, topical nasal decongestants for short-term use under medical supervision are safer alternatives 1

High-Risk Cardiovascular Patients

• Phenylephrine can precipitate angina in patients with severe arteriosclerosis or history of angina, exacerbate underlying heart failure, and increase pulmonary arterial pressure 3
• Use with caution in patients with arrhythmias, coronary artery disease, cerebrovascular disease, hyperthyroidism, or glaucoma 1

Guideline-Based Management Recommendations

Screening and Assessment

• The American College of Cardiology recommends screening all patients with hypertension or at risk for hypertension for OTC medications, supplements, and substances that may increase blood pressure 6
• Take a careful history including prescription medications, OTC substances, illicit drugs, and herbal products 6

When to Avoid Decongestants Completely

• Severe or uncontrolled hypertension 5, 1
• Recent myocardial infarction or unstable angina 3
• Severe coronary artery disease 1
• Uncontrolled heart failure 3

Safer Alternative Therapies

The American College of Cardiology recommends considering these alternatives instead of oral decongestants 5:

1. Intranasal corticosteroids (first-line, safest long-term option) 1
2. Nasal saline irrigation 5, 1
3. Second-generation antihistamines alone (loratadine, cetirizine, fexofenadine—do not affect blood pressure) 1
4. Topical nasal decongestants (oxymetazoline)—safer than oral but strictly limited to ≤3 days maximum to avoid rhinitis medicamentosa 1

Important Clinical Considerations and Pitfalls

Drug Interactions

• The pressor effect of decongestants is potentiated by MAO inhibitors, β-adrenergic blockers, tricyclic antidepressants, and other sympathomimetic agents 3
• Never combine multiple sympathomimetic decongestants, as this can lead to hypertensive crisis 1
• Concomitant caffeine use may produce additive adverse effects including elevated blood pressure, insomnia, irritability, and palpitations 1

Monitoring Requirements

• The Hypertension guideline advises monitoring blood pressure closely during initiation of any new OTC medication, especially in the first weeks of treatment 6
• When feasible, reduce or discontinue drugs associated with increased blood pressure and use alternative agents 6

Duration of Use

• Use decongestants for the shortest duration possible 5
• The American College of Cardiology recommends that patients taking pseudoephedrine for extended periods (e.g., one year) should discontinue and consider alternative therapies due to cardiovascular risks and limited evidence for long-term use 7

Other OTC Medications That Increase Blood Pressure

NSAIDs

• NSAIDs can increase blood pressure by 3-6 mmHg in patients with controlled hypertension, with effects appearing within the first weeks of treatment 6
• The American College of Cardiology recommends avoiding systemic NSAIDs when possible and considering acetaminophen, tramadol, or topical NSAIDs instead 5, 6

Caffeine

• Coffee use is associated with acute increases in blood pressure; long-term use is not associated with increased blood pressure or cardiovascular disease 5
• Limit caffeine intake to <300 mg daily and avoid in patients with uncontrolled hypertension 5, 6