When to stop taking high blood pressure medication
High Blood Pressure: What You Need to Know About Medications
I'm here this morning with dr. Luke
laughin who's a staff cardiologist in
our section of preventive cardiology and
he's also a clinical specialist in
hypertension and he's here to talk to us
about high blood pressure and control of
high blood pressure and a lot of
questions that patients ask about high
blood pressure doctor laughs and the CDC
says that one in three people in the
United States have high blood pressure
it's just a large population of patients
so the first question that I have is
about medications that seems to be the
biggest question as a nurse that I get
you know how do you even choose
medications how do you start a patient
on medication when do you start a
patient on medications so generally
there's three classes of medications
that are our first line treatment for
hypertension and the guidelines for when
to start medications on patients have
been changing recently but we tend to
say that if they've had elevated blood
pressures two or more visits in the in
the clinic then we should consider one
lifestyle modification but then based on
the level of potential addition of
medical therapies so the three classes
of medications that we prescribe as
first-line therapy are as follows the
first one is Rena angiotensin system
blockers so they're essentially what
they do is they block this hormone
system that regulates blood pressure and
fluid within the body another class of
medicines that people are often on are
diuretics the water pills and they help
get rid of sodium and water via the
urine and then finally there's another
class of medicines called calcium
channel blockers and how they work is
they relax the blood vessels within the
body to provide lower blood pressures as
well now there's other medication
classes there's numerous other ones that
we can use to treat hypertension and in
certain patient populations they'd be
maybe more efficacious
for example patients with certain
cardiovascular disease recent heart
attacks etc they may be prescribed a
beta blocker which is another class of
medicines so there's many different
choices but those are the first-line
therapies and how come some patients are
only on one medication sometimes
patients are two medications how do you
make that choice for a patient so that's
generally based on how much blood
pressure lowering we need there's good
data that being on two medications that
have some synergy so they work together
effectively lowering blood pressure at
moderate doses can be better than just a
maximum dose of one medication right now
the guidelines suggest that anyone that
has multiple blood pressures in the
office that are higher than 140 over 90
generally should be started on
combination therapy so two doses maybe
not at the maximum strength but two
different medications so are there side
effects that people should think about
or watch out for yeah definitely there
is the nice thing about blood pressure
medicines is that they've been around
for a while and are well studied so
these side effects are predictable the
one complaint or the one comment that
oftentimes physicians hear is that oh
I'm tired when I start taking my blood
pressure medicines especially if you
started at a higher blood pressure and
we're significantly lowering it that can
be classified as a side effect but
that's just the body adjusting to the
lower blood pressures in terms of
specific medication classes and their
side effects oftentimes when we begin a
diuretic especially the stronger
diuretics people can complain of
cramping in their legs this generally
tends to last for two to three days it's
oftentimes attributed to low potassium
although it's not always low potassium
it's more likely to be the fluid shifts
the body getting rid of extra water and
salt and so we can see that but the nice
thing that we tell them is that after 2
or 3 days especially if you're on a low
salt diet this cramping tends to
away other medicines that commonly have
that have predictable side effects
include calcium channel blockers so the
most commonly used is one called
amlodipine or the brand name is norvasc
about on the 5 milligram dose which is a
moderate dose about 30% of people
explore experience some degree of lower
extremity swelling so a little bit of
puffiness and their ankles or feet it's
not dangerous
it's just cosmetically some people don't
like it and then at the 10 milligram
dose about a little bit more than half
of people actually have this this side
effect it's important to remember that
that's how the medicine works it's a
vasodilator it increases the size of the
blood vessels so you are going to have
some degree of swelling but as I said
it's not dangerous so are there any of
those side effects that they should
definitely call their doctor for or are
these things that just kind of go away
what time are well I think coming back
to what I said about being tired um you
don't want to be so that you so tired
that you can't get out of bed that just
suggests that perhaps your doctor
overshot in terms of how much blood
pressure medicine that we're giving we
don't want people walking around with
blood pressures under a hundred
millimeters of mercury for their
systolic similarly certain medicines
especially in the class of medicines
called ACE inhibitors so the most
commonly used is lisinopril they can
have effects such as swelling of the
lips the airway those are side effects
that and you need to alert your doctor
promptly and if it's it's significant
and you need to go to the emergency
department
do you ever send patients home with to
do home blood pressure monitoring is
that something that would help with the
medications too yes I think definitely
it's really a cornerstone of my practice
which predominantly involves patients
that have resistant hypertension so
blood pressure not controlled on three
different medicines
and we do it very commonly and that's
actually one of the emphases of the
newer 2017 hypertension guidelines by
the American Heart Association in
American College of Cardiology and what
we recommend is when we've changed
antihypertensive therapy to check three
to four times per week in the morning
before you take your medicines and then
what I have is I have patients send them
to me about two or three weeks after
their they might keep it on an Excel
spreadsheet or they may just write it
down on a piece of paper and they send
it to me via via our electronic medical
record so we can make adjustments in
between appointments rather than waiting
three or six months till we see them
again and it can be very helpful in
terms of guiding what we do if we add
subtract or change medicines okay so you
said just once a day in the morning
because I know patients sometimes they
like should I take it not in the morning
should I take it three times a day so
you're just really saying they could
take it once a day in the morning right
that's that's generally what we
recommend throwing in an evening blood
pressure is fine every once in a while
however we know that in the majority of
people blood pressure tends to decrease
at night it drops about ten to fifteen
percent then starting at 4:00 a.m.
there's a sharp upward rise in blood
pressure Peaks in most people between
6:00 a.m. and noon not coincidentally
that's when the majority of strokes and
heart attacks between 6:00 a.m. and noon
so what we try and do is we try and
catch that peak blood pressure and make
sure you're protected throughout the day
one common mistake that I see patients
making is they say okay well I'm going
to take my blood pressure medicine and
then I'm going to check two or three
hours after taking I don't think that's
the right strategy to take because that
can give people a false sense of
security that's when the medication is
having its peak effect is about two
although it works all day it's having
its peak effect two to three hours after
but we want to know when it's the
highest and treat so that it's under
that so a lot of times patients ask
should I take my blood pressure medicine
at night or in the morning that's a very
timely question because there's actually
a trial released
in the past week looking at this it was
published in the American Heart
Association as hypertension journal
called the Harmony trial and what they
did was they said one group of patients
can take their blood pressure medicine
in the morning all in the morning or all
at night and they look to see if there
was a difference in 24-hour blood
pressure so they wore a monitor for 24
hours and they showed no difference
whatsoever I was lucky enough to have
the opportunity to write the editorial
in that that accompanied that paper and
what it comes down to likely is that the
medicines we use are our long-acting
the majority of them so they work over
24 hours so it probably doesn't make a
difference when we're taking our
medicines in the morning right now there
is one caveat to that and that is
there's certain medicines that we
probably don't want to take it at night
because they're going to disrupt our
sleep and we know that disrupted sleep
can lead to elevated blood pressures so
for example if someone's taking a
diuretic a water pill they shouldn't be
taking that at 7 o'clock 8 o'clock at
night because it's going to have a peak
effect when you're going to bed at 10:00
or 11:00 o'clock
similarly the class of medicines calcium
channel blockers if someone has
significant acid reflux or heartburn if
they're taking that at night it can
sometimes relax the muscles in the
esophagus on the stomach and the
connection between those and so it can
worsen acid reflux so if that's the case
we recommend they take that medicine in
the morning as well I'm sure that you
get this question a lot can I come off
my medicine once I start a blood
pressure medicine is that ever a chance
that I could take less or get off that
medication yes it's a very common
question that we get and it really
depends on the patient themselves now if
there's if someone is overweight has a
sedentary lifestyle so they're not
exercising or active and has a high
sodium diet then there is a possibility
and that they can come off blood
pressure medicine it depends obviously
how high their blood pressure is there's
good data that shows that by losing
weight exercising and a low sodium diet
in combination
we can drop our systolic blood pressure
by at least 15 millimeters of mercury
maybe even more and that's oftentimes
all patients need now there is a subset
of patients that there may be 7075 they
have stiff blood vessels and that's an
effective aging and somewhat at genetics
as well those patients they may not be
overweight and they may be active and
they may be watching their sodium but
their blood pressure is still high those
patients I tell them no they cannot come
off medicines but we try and keep them
at the same number of medicines just try
and optimize the dosing for them get
them on the most potent medicines to
control their blood pressure while also
minimizing side effects very interesting
so if you could leave this with the
three most important points you would
want to give your patients who have high
blood pressure what would that be I
think the the first thing is that it's
understandable no one likes to take
medicines I don't like to take medicines
however that's the problem with
hypertension is that oftentimes we don't
know when our blood pressure is high
that's why they call it the silent
killer and it's the number one risk
factor for things like stroke so so when
we start medicines and move someone from
let's say a blood pressure of 160 or 170
systolic down to 140 or 130 yes you may
feel tired when that when you start
taking the medicine that's natural it's
just the body adjusting to living at a
lower blood pressure but that effect
goes goes away after 10 days to two
weeks and so that's important to know
that don't give up on it just because
you're a little bit more tired because
it's gonna you're gonna feel better in
the long run and you're gonna protect
your major organs your kidneys your
heart and your brain so that would be
point number one point number two is
have a discussion with your doctor about
the side effects associated with some of
these men
because often comes it can be a
trade-off and just because one person
can tolerate lower blood pressures for
the systolic you maybe can't so have a
have a discussion with them and then the
third thing I'd say is that for those
patients that may be taking three or
more medicines hopefully in let's say
when the next five to ten years we'll
have therapies that are not medicine
based that they're more device based
therapy I actually have a call right
after this podcast talking with a
company that we're looking to to start
at least do some clinical trials than
that so there is the possibility in the
future of device based therapy for
hypertension where we'll eliminate the
need for medications very interesting
well thank you so much for being here
today
I want to thank dr. laughin for being
with us to answer questions about high
blood pressure great thanks very much
for having me
