Decongestants and Hypertension: Making Wise Choices When Selecting OTC Medications

DECEMBER 20, 2017
Yvette C. Terrie, BSPharm, RPh
To effectively manage hypertension, the more than 75 million adults in the United States with the condition should be compliant with their prescribed drug therapies, change their diets, avoid stress when possible, and use caution when taking other medications, including OTC ones, and supplements to avoid drug–drug interactions.1 It is particularly important for those with hypertension to be cautious when selecting OTC medications for cough, cold, and flu because the use of decongestants can exacerbate hypertension. Decongestants are indicated for the temporary relief of nasal and eustachian tube congestion and for coughs associated with postnasal drip.2 This class of drugs stimulates the alpha-adrenergic receptors, constricting blood vessels and thereby decreasing sinusoid vessel enlargement and edema of the mucosal areas.2 Because 1 of the adverse effects associated with the use of decongestants is cardiovascular stimulation, including elevated blood pressure (BP), tachycardia, palpitations, and arrhythmia, the use of this class of agents to relieve nasal congestion may exacerbate conditions that are sensitive to adrenergic stimulation, such as hypertension, ischemic heart disease, and coronary artery disease; the agents may also interact with several other medications.2  Individuals with cardiovascular disease, including hypertension, should use decongestants only under the direction of their primary health care provider.2,3 Individuals with hypertension should be aware that the use of decongestants may increase BP or hinder or interfere with the effectiveness of some antihypertensives, according to the American Heart Association (AHA).3 The AHA also recommends that those with hypertension avoid medications that are high in sodium.3

Results from a 2005 meta-analysis showed that the decongestant pseudoephedrine, which is found in more than 135 medications, modestly increased systolic BP and heart rate.4 The study results also showed that pseudoephedrine did not affect diastolic BP and the readings of greater BP were observed with higher doses and in those formulations that were immediate release.4 The study concluded that clinicians should consider the “risk-benefit ratio before using sympathomimetic agents in those considered to be high risks.” 4 It is important to note that there are a lack of data regarding the safety and efficacy of the decongestant phenylephrine in those with hypertension.5

Additionally, the FDA requires that the following warning be included on the label of all products that contain oral or topical decongestants: “Do not use this product if you have heart disease, high blood pressure, thyroid disease, diabetes, or difficulty in urination due to enlargement of the prostate gland, unless directed by a doctor.”6

Pharmacists are in a pivotal position to educate and guide patients who have hypertension in the proper selection and use of OTC cough, cold, and flu products (Table). Patients with hypertension who are seeking advice on the available products that are safe to use should be steered toward products that do not contain decongestants and be directed to use products such as Coricidin HBP from Bayer Consumer Health, which is a product line marketed specifically to patients with hypertension. There is also a product line marketed by Procter & Gamble, including DayQuil HBP Cold & Flu and NyQuil HBP Cold & Flu, for those with hypertension, and these are decongestant free as well.  



For patients who have hypertension when no other contraindications are present, such as an allergy to product ingredients, pharmacists may recommend the nasal decongestant propylhexedrine, marketed as Benzedrex from B.F. Ascher & Company, Inc, which is not required to carry the warning against use in patients with hypertension.7 Additionally, inhalers that contain the decongestant levmetamfetamine also do not contain the FDA warning.8 Pharmacists can also recommend the non-medicated nasal strips marketed as Breathe Right from GlaxoSmithKline for relief from nasal congestion. Non-medicated inhalers such as Non-Medicated Vicks VapoInhalers from Procter & Gamble that contain menthol are also available. Additionally, for temporary relief of nasal congestion, pharmacists can recommend nasal steam inhalation, which can be very effective. There is also a variety of personal steam inhalation machines on the market, as well as a host of essential oil diffusers that emit the aromas of essential oils, such as peppermint and eucalyptus, throughout a room, which may provide temporary relief from nasal congestion. Patients should be advised to discuss any concerns with their primary health care provider prior to using any of these therapies.  

Conclusion
During counseling, pharmacists should remind patients who have hypertension to always seek medical counsel when in doubt about the use of any OTC product to avoid potential drug–drug interactions or contraindications. Patients should be encouraged to always read the labels of medications prior to use and to adhere to the recommended directions. Pharmacists can also suggest various nonpharmacological measures that patients may employ to relieve cough, cold, and flu symptoms, such as congestion, including vaporizers, humidifiers, rest, and adequate hydration. Counseling provides pharmacists an opportunity to increase awareness and educate patients with hypertension about other OTC medications that they should avoid or use with caution. They can remind patients with hypertension about the critical nature of self-monitoring BP routinely, remaining compliant with prescribed therapy, adhering to low-sodium diets, and routinely following up with their primary health care providers. Pharmacists can be instrumental in recommending appropriate measures to treat congestion in those with hypertension without negatively affecting their BP.   
 
Yvette C. Terrie is a clinical pharmacist and medical writer based in Haymarket, Virginia.

References
  1. High blood pressure. CDC website. cdc.gov/bloodpressure/index.htm. Updated September 5, 2017. Accessed October 28, 2017.
  2. Scolaro KL. Colds and allergy. In: Krinsky DL, Ferreri Stefanie P, Hemstreet B, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th ed. Washington, DC: American Pharmacists Association; 2015.
  3. Understanding over-the-counter (OTC) medications and high blood pressure. American Heart Association website. heart.org/HEARTORG/Conditions/HighBloodPressure/MakeChangesThatMatter/Understanding-Over-the-Counter-OTC-Medications-and-High-Blood-Pressure_UCM_303245_Article.jsp#.WfdUa2hSw2x. Updated October 2016. Accessed October 28, 2017.
  4. Salerno SM, Jackson JL, Berbano EP. Effect of oral pseudoephedrine on blood pressure and heart rate: a meta-analysis. Arch Intern Med. 2005;165(15):1686-1694. doi: 10.1001/archinte.165.15.1686   .
  5. Hatton RC, Winterstein AG, McKelvey RP, Shuster J, Hendeles L. Efficacy and safety of oral phenylephrine: systematic review and meta-analysis. Ann Pharmacother. 2007;41(3):381-390. doi: 10.1345/aph.1H679.
  6. US Food and Drug Administration. CFR - code of federal regulations title 21. www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=341.80. Updated April 1, 2017. Accessed October 28, 2017.
  7. Benzedrex FAQ. B.F. Ascher & Co, Inc, website. bfascher.com/questions/benzedrex-faq/. Accessed October 30, 2017.      
  8. Vapor Inhaler (levmetamfetamine) [package insert]. Deerfield, IL: Walgreens; 2016. dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=77924474-ccc7-497b-9168-91490bcfadfc. Accessed November 1, 2017.


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