What are the recommended blood pressure medications for a patient with acute ulcerative colitis, hypertension (high blood pressure) likely exacerbated by prednisone, and currently taking prednisone and upadacitinib (Janus kinase inhibitor)?

Blood Pressure Management in Acute Ulcerative Colitis Patients on Prednisone and Upadacitinib

For patients with acute ulcerative colitis on prednisone and upadacitinib who develop hypertension, calcium channel blockers (such as amlodipine) or thiazide diuretics are the preferred first-line antihypertensive agents, as they lack significant drug interactions with JAK inhibitors and do not interfere with the immunosuppressive regimen.

Rationale for Antihypertensive Selection

Primary Considerations

• Prednisone-induced hypertension is common in acute severe ulcerative colitis, as intravenous corticosteroids (hydrocortisone 100 mg three to four times daily or equivalent) remain the standard initial treatment 1.

• Upadacitinib requires blood pressure monitoring for the first 3 months after treatment initiation, then every 6 months, with patients having preexisting hypertension needing weekly home monitoring for the first month 1.

• Calcium channel blockers and thiazide diuretics are preferred because they do not significantly interact with JAK inhibitor metabolism or increase infection risk in immunosuppressed patients.

Specific Drug Recommendations

First-line options:

• Amlodipine 5-10 mg daily - long-acting calcium channel blocker with once-daily dosing, no significant drug interactions with upadacitinib or prednisone
• Hydrochlorothiazide 12.5-25 mg daily - thiazide diuretic, though monitor for electrolyte disturbances given the risk of hypokalemia in acute colitis 1

Second-line options if first-line inadequate:

• ACE inhibitors or ARBs can be added, though monitor renal function closely given potential dehydration risk in active colitis 1

Critical Monitoring Parameters

Blood Pressure Monitoring Schedule

• Weekly home blood pressure monitoring for the first month after starting upadacitinib in patients with preexisting hypertension 1
• Every 3 months for the first 3 months of upadacitinib therapy 1
• Every 6 months thereafter during maintenance therapy 1

Electrolyte Management

• Potassium supplementation of at least 60 mmol/day is usually necessary in acute severe ulcerative colitis, as hypokalemia can promote toxic dilatation 1
• Monitor serum potassium closely if using thiazide diuretics, as both the diuretic and active colitis increase hypokalemia risk 1
• Correct hypomagnesemia promptly, as it also contributes to toxic megacolon risk 1

Drugs to Avoid

Beta-blockers and non-dihydropyridine calcium channel blockers (verapamil, diltiazem):

• Should be avoided or used with extreme caution as they can slow heart rate or AV conduction 1
• Ozanimod guidelines specifically warn against drugs that slow heart rate, and this principle applies broadly to sphingosine-1-phosphate modulators 1

NSAIDs:

• Must be withdrawn in acute severe ulcerative colitis as they can exacerbate disease 1
• This eliminates their use for any indication including hypertension-related complications

Special Considerations for Acute Severe UC

Concurrent Management Priorities

• Intravenous fluid and electrolyte replacement to correct dehydration takes precedence, which may improve blood pressure control 1

• Thromboprophylaxis with subcutaneous low-molecular-weight heparin is mandatory in all hospitalized acute severe UC patients unless contraindicated, and rectal bleeding is NOT a contraindication 1

• Joint gastroenterologist and colorectal surgeon management is required for acute severe UC, ensuring coordinated decision-making about both the colitis and its complications 1

Timing of Antihypertensive Initiation

• Start antihypertensives promptly if blood pressure remains elevated after initial fluid resuscitation
• Do not delay treatment waiting for corticosteroid taper, as prednisone will be continued for weeks and hypertension control is essential to prevent cardiovascular complications
• Reassess need for antihypertensives during corticosteroid taper, as blood pressure may normalize with dose reduction

Upadacitinib-Specific Safety Monitoring

Cardiovascular Risk Assessment

• Patients at high cardiovascular risk may warrant consideration of upadacitinib 15 mg maintenance dose rather than 30 mg after achieving clinical response 2

• Regular monitoring includes assessment of clinical response at 8-12 weeks after transitioning to maintenance dosing and ongoing monitoring for adverse events 2

• Extended induction therapy (16 weeks total with upadacitinib 45 mg) may be considered for incomplete responders at 8 weeks, with 59.1% achieving clinical response by week 16 3

Long-term Considerations

• Do not taper upadacitinib due to risk of disease flare, as ulcerative colitis requires lifelong maintenance therapy 2

• Maintain thromboprophylaxis awareness in high-risk patients throughout treatment, as JAK inhibitors carry venous thromboembolism risk 2