Resistance to antihypertensive therapy due to NSAIDs

An 80-year-old man is evaluated in the office during a routine examination. He has a history of hypertension, and chronic osteoarthritis was diagnosed 20 years ago. His hypertension has been well controlled on submaximal dosages of both atenolol and hydrochlorothiazide. Three months ago, he began taking ibuprofen.

On physical examination, heart rate is 60/min and blood pressure is 180/90 mm Hg without orthostatic changes. There is trace peripheral edema.

Laboratory Studies
Blood urea nitrogen 40 mg/dL
Creatinine 1.5 mg/dL
Sodium 134 meq/L
Potassium 4.9 meq/L

Which of the following treatment strategies is indicated for this patient?
A Add lisinopril
B Discontinue ibuprofen
C Increase the atenolol dose
D Increase the hydrochlorothiazide dose


Key Point
Nonsteroidal anti-inflammatory drug use is a common cause of resistance to antihypertensive therapy.

Answer and Critique (Correct Answer = B)
Discontinuation of ibuprofen is indicated for this patient. Nonsteroidal anti-inflammatory drugs (NSAIDs) frequently affect sodium excretion. However, these agents are routinely used by elderly patients, who are particularly vulnerable to the blood pressure–raising effects of these drugs because of the change in sodium excretion. Most elderly patients have musculoskeletal conditions that warrant some form of therapy, but long-term daily treatment with NSAIDs may not be necessary. Alternative treatment strategies, such as physical therapy or therapy with acetaminophen, are indicated in this setting.

Discontinuing this patient's NSAID therapy is an appropriate next step to try to decrease his blood pressure. This strategy should be attempted before increasing his current medications or adding new medications, particularly because NSAIDs may contribute to renal and electrolyte disorders when used concomitantly with angiotensin-converting enzyme inhibitors or when taken by volume-depleted patients.
Bibliography

1. Gaziano JM. Nonnarcotic analgesics and hypertension. Am J Cardiol. 2006;97:10-6. Epub 2006 Mar 30. [PMID: 16675317] [PubMed]