Amiodarone Does NOT Worsen Hypertension
Among the medications listed, amiodarone is the only agent that does not worsen hypertension. The other four medications—cyclosporine, erythropoietin, contraceptives, and NSAIDs—are all well-established blood pressure-elevating agents according to major hypertension guidelines.
Medications That DO Worsen Hypertension
Cyclosporine
- Cyclosporine causes a dose-dependent increase in blood pressure that is both statistically and clinically significant 1.
- Lower doses (1-4 mg/kg/day) increase mean blood pressure by approximately 5 mmHg, while higher doses (>10 mg/kg/day) increase it by 11 mmHg on average 2.
- The ACC/AHA guidelines recommend considering conversion to tacrolimus in hypertensive patients, as it may have fewer effects on blood pressure 1.
- This blood pressure elevation increases cardiovascular risk including stroke, myocardial infarction, and heart failure 2.
Erythropoietin
- Erythropoietin is explicitly listed as a drug-induced cause of elevated blood pressure in the JNC 7 guidelines 1.
- The ACC/AHA 2017 guidelines also identify erythropoietin as a medication that can cause elevated blood pressure 1.
Oral Contraceptives
- Combined oral contraceptives cause small but significant increases in blood pressure, with overt hypertension developing in approximately 5% of users 3, 4.
- High-dose estrogen formulations can increase blood pressure by 6/3 mmHg 3.
- The ACC/AHA recommends using low-dose (20-30 mcg ethinyl estradiol) agents or progestin-only forms of contraception, and avoiding use in women with uncontrolled hypertension 1, 3.
- The estrogenic component appears to be the primary factor producing abnormalities in the renin-angiotensin-aldosterone system 4.
NSAIDs
- NSAIDs are consistently identified as blood pressure-elevating agents that should be avoided or limited in hypertensive patients 1.
- Meta-analyses show NSAIDs increase mean arterial pressure by approximately 5 mmHg 5.
- The 2020 ISH guidelines specifically recommend avoiding high doses of NSAIDs in patients with inflammatory rheumatic diseases and hypertension 1.
- NSAIDs can reduce the efficacy of several antihypertensive drugs including diuretics, beta-blockers, and ACE inhibitors through prostaglandin inhibition 6, 5.
- When analgesics are necessary, acetaminophen may be preferable to NSAIDs in patients with resistant hypertension 1.
Amiodarone: The Exception
Amiodarone is not mentioned in any major hypertension guideline as a blood pressure-elevating agent 1. Unlike the other medications listed, it does not appear in the comprehensive tables of drugs that cause elevated blood pressure in the ACC/AHA or JNC guidelines.
Clinical Implications
- When evaluating resistant hypertension, the 2020 ISH guidelines emphasize excluding substance-induced increases in blood pressure as a first step 1.
- The ACC/AHA recommends screening all hypertensive patients for medications that may raise blood pressure or interfere with antihypertensive therapy 1, 7.
- Blood pressure should be monitored closely when initiating any of the blood pressure-elevating agents, with recognition that adjustments to the antihypertensive regimen may become necessary 1.