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Doctors' Answers to "Frequently Asked Questions" - Hypertension

These comments are made for the purpose of discussion and should NOT be used as recommendations for or against therapies or other treatments. An individual patient is always advised to consult their own physician.

Hypertension; Norvasc [posted 1/14/99]
Question: I am a 290 pound, 6'5", 54 year old white male. I have been taking 10 mg of norvasc every morning for the last 2.5 years. In the last year my ankles have swollen a great deal, the hair on my legs has fallen off at the ankles and there are red spots in the area of the ankles. I get temporary relief by elevating my feet in the evening. When I have to drive on longer trips the situation seems to deteriorate. As a young man I was an athlete competing in contact sports and had sprained and broken both ankles at various times. Are the side effects that I have described an acceptable reaction to this drug? Also, will I be on hypertension medication for the rest of my life? When I was first diagnosed with high blood pressure four years ago I was tested on various medications with finally stopping on norvasc. Other medications caused coughing, etc. Have any new drugs to control high blood pressure become available in the last four years?

Answer: Pedal edema is one of the common side effects for the calcium channel blockers. As a class, norvasc is less than some, but clearly the cause. As to the length of time for treatment, weight loss is usually the only corrective measure you can take. Sometimes it only takes 10-20 pounds for a marked improvement. As to "new" drugs, give me a list of what you tried. Cozaar and the angiotensin blocker drugs might be an option if you haven't tried them.

Hypertension [posted 1/8/99]
Question: My hypertension is being controlled by Spironolactone and Norvasc. I have been diagnosed with hyperaldosteronism. The nodules in the adrenal gland are too small to be properly detected by an MRI and CAT scan, so surgery to remove them is not appropriate. So my instructions from my doctor is to stay on my medication (Norvasc and Spironolactone). I am happy to stay on these medicines since they do control the blood pressure (usual reading 145 over 85). However, my web-surfing has come up with some disturbing information about Spironolactone. The "Informed Drug Guide" says:
a) In Great Britain Spironolactone is not recommended as a hypertensive, as tumors have been detected in animal experiments.
b)The only indication where Spironolactone can be given to men is for cirrhotic ascites(whatever that is) due to the antiandrogenic effect of Spironolactone.
c) They give Spironolactone a 2 out of 4 rating for lifetime value, a 2 out of 4 value for symptomatic value and a 1 out of 4 value for safety. This is very disturbing! My nipples are sore, but the doctor says that this is a nuisance factor rather than an indication that there is a problem. What is your opinion of the safety and effectiveness of this drug? What do you know about the tumors antiandrogenic effect? Are there any substitute drugs that would be safer and just as effective? I would appreciate any assistance and advice that you can give me.

Answer: No other effective drugs unfortunately. However, the sore nipples will persist and about 20% of men will develop breast tissue (the drug is similar in structure to estrogen). As to the tumors, no good evidence of this in the U.S. currently, and we tend to be a lot more conservative than Britain in this area. I'd stick with the medication, but use as little as possible (due to the breast problem).

Hypertension Treatment [posted 1/5/99]
Question: I've been taking Cardura for high blood pressure and frequent urination during sleeping hours. I take a 4 mg tablet before going to bed around 10:30 p.m. Seems to help with the frequent urination, but seems to do very little for my blood pressure. When I monitor my blood pressure, it always seemed to be highest when I first got up in the morning. It now seems to be running 180/100 with the Cardura. I also had tried Altase and Cardizem prior to the Cardura. They didn't seem to help either. Any suggestions? I'm not a smoker and I rarely use alcohol. I don't use caffeine and am about 10 lbs. overweight. Someone recommended Taurine from the Health Food Store.

Answer:I'd try focusing on low renin hypertension drugs like diuretics, etc. Also, you can push the dosage of the cardura. What dosage are you on?

Making Hypertension Medication More Effective [posted 11/13/98]
Question:I have Diabetes type 2 and hypertension, one of the medications are Avapro, and am taking 150 mg per day, but it seems that later in the day it is not quite as effective as the morning pressure check, could i take additional avapro later in the day.

Answer:Yes, or split the dosage.

Hypertension & Beta Blockers [posted 10/8/98]
Question:Having read the latest about Beta Blockers, it seems that I am not using any of them. Would it make sense to perhaps use a beta blocker instead of the imdur and diovan that I am currently taking? I can never tell the difference between heartburn and angina, except it seems the angina produces gas but generally I know only when I take the Nitrospray. Is there anyway to really know? Forgot to mention nitrolingual spray .4mg that I use perhaps 2-4 times a week.

Answer: Usually an effective drug. But, there are some contraindications you need to discuss this with your doctor. Side effects which limit its use are usually fatigue.

Hypertension, GERD, and Medications [posted 8/11/98]
Question: I have essential hypertension, an essential tremor, and gerd. I am taking Lotensin without problem, but I am maxed out. Since mid January 1998 I have had adverse reactions to 2 Calcium Channel Blockers and one Beta Blocker. In the past I have experienced horrible reactions to Diuretics, beta blockers and a calcium channel blocker gave me an ulcer. I am allergic to sulfur. Three weeks ago Sular put me in the emergency room with hypotension, rapid heartbeat, edema (swelling and red all over), tremors, etc. My doctor gave me a T-channel blocker (prosar?). I looked it up on the internet and found a warning that it should not be taken with propulsid, but I take propulsid for gerd. My doctor didn't consider. So he gave me Norvasc, which is a A calcium channel blocker. I read that the side effects include tremor, weight gain, headache and edema? I have been on a rigorous routine of weight and aerobics training and on a weight watchers diet. Losing weight is very hard for me. What can I expect?

Answer: First, have you checked your blood pressure at home d atnsure that it really is elevated ? Secondly, I don't see that you have tried ACE inhibitors or drugs like Cozaar. These have minimal side effects in most patients and would not have a problem with Propulsid metabolism.

Hypertension Medication [posted 8/6/98]
Question: My husband is 45 years old and has been taking lopressor for about 8 months now. He has totally lost his sexual drive. Is there another drug for hypertension that would not have such a severe side effect?

Answer: The best thing is to start working your way through a list of bp medications and see which ones work for his blood pressure, but have the less bothersome side effects. In general, ACE inhibitors and calcium channel blockers will have the least effect on sexual performance. However, I have some patients who can't tolerate either and are ok on beta blockers like lopressor.

Hypertension Medication [posted 8/5/98]
Question: I am presently taking the following medications for hypertension: norvasc 5 mg twice daily, minoxidil 2.5 mg twice daily and demadex 20 mg once daily with no real improvement in my condition. I usually run a reading of 146/88 and most recently 162/98. I have a history of becoming immune to medications. Is there a better route to go?

Answer: What medications have you already tried? I certainly would try an ACE inhibitor due to effectiveness and lack of side effects. Also, you aren't on large doses of Norvasc - this can be easily increased.

Libido and Hypertension Drugs [posted 8/4/98]
Question: I am a 37 year old caucasian male who was diagnosed with severe high blood pressure 5 years ago. Since then, I have taken several different drugs to treat the condition. My doctors tried diuretics and beta blockers, and then calcium channel blockers during the first three years. Both or those treatments were stopped due to various unacceptable side effects including loss of sexual desire and performance. I have been using ACE inhibitors (currently Zestril) for the past two years. The Zestril has my blood pressure under control (I also watch my diet and get regular aerobic exercise). However, my sexual desire is still almost non- existent and I have little luck in maintaining erections the few times that I am “in the mood”. I have recently been told by two different individuals that their doctors have put them on a combination of Cozaar and Linoten to address similar libido problems they were having due to the ACE inhibitors they were using (one was on Zestril and another on Accupril). Does this combination treatment sound like one that I should discuss with my doctor considering the results I have had from past drugs? I understand that Linoten is a form of minoxidil which I know is used to regrow hair. I don't have a hair loss problem, and am concerned about an increase in body hair. Is body hair growth a common side effect, and if so, to what degree?

Answer: Since ACE inhibitors are working so well, I suspect Cozaar would work in an equivalent manner. I am not familiar with Linotin, but it is probably generic minoxidil. I doubt you would need this in addition to the Cozaar. The problem with minoxidil other than hair is that it is really a powerful bp medication. I would start with the Cozaar first. Also, what is the cause of your hypertension? ACE inhibitors work in patients with high renin levels, but are your renal arteries narrowed? The reason that I ask is that this is a potentially correctable cause, which consequently, could decrease or stop your blood pressure medications. I would work on both fronts.

Hypertension Medication [posted 8/4/98]
Question: My stepfather is currently taking Hytrin 2 mg, Ziac 5 mg and Zestril 20 mg QD for hypertension. I was wondering if there is an alternative that could combine the effects of these 3 medications. Is it unusual to be taking 3 different drugs to treat the same problem?

Answer: Actually he is on 4 since Ziac is a combination of a beta blocker and a diuretic. There are two schools of thought on hypertension. First school says keep it simple and use the least possible - increasing the dosage as necessary until the hypertension is controlled. The second says that side effects (negative ones at least) can be minimized with smaller doses and adding different medications rather than increasing the dosage. I guess it would depend on how well controlled his blood pressure is and how many side effects he has as to which direction he/his physician prefer to go.

Hypertension Medication [posted 7/24/98]
Question: I have been using nifidepine for high blood pressure. The pressure is still reading high. Systolic is from 137-154 and diastolic 89-110. I am using "Walgreens model 93" digital blood pressure monitor. I am a black male, 180 pounds, 59 years old. I avoid as much salt, pork and beef as possible. I do not have a sugar problem. What other medication would you suggest using with the given information?

Answer: Usually a diuretic would be next for most expected low renin hypertensive patients.

Hypertension Related Difficulty in Running
Question: I am a 58-year-old woman who has been treated for hypertension since June of this year (about 5 months). I have been taking 20 mg Zestril once a day. Up until the treatment started, I had been running about 4 times a week for a total of about 17 miles. Now I cannot run more than 6 to 9 minutes. What I experience feels like my legs are swelling to the point of bursting and it’s very uncomfortable, but not painful. However, I do seem to lose the ability to control the movement of my feet and legs. Walking continues to be uncomfortable for 2 - 4 blocks. From then on I can only run several yards before having to stop again. I still walk quite a bit, 30-60 minutes about 5 times a week without difficulty. As the weather got colder here recently I found my extremities very sensitive to cold. On a few occasions losing all color in my fingers through the first 2 knuckles. My doctor has recommended that I switch to Lotensin (starting at 10 mg once a day) to see if it would help.

Answer: There are two possibilities. First, that these symptoms are all due to the BP medication. This is unusual for the class of drugs(ace inhibitors), but is easy to test. Stop it a couple of days and see if the symptoms disappear. Second, this sounds very much like Raynaud's Phenomenon. This is spasm of the small peripheral arteries usually induced by vibration, trauma or cold. I have several women who have had this problem with aerobic exercises for example. In general, beta blockers can exacerbate this problem, generally not ace inhibitors. But, the treatment is to use calcium channel blockers, particularly nifedipine or a similar drug (even in those patients without hypertension). Lotensin belongs to the same class of drug and I doubt that will help with the symptoms.

High Blood Pressure
Question: What Medication and/or conditions will cause water retention?

Answer: Non-steroidal anti-inflammatories, some calcium channel blockers, and occasionally high dose aspirin. These are the main actors.

Hypertension Medications
Question: Having moderate hypertension and taking Hyzaar, an ace inhibitor, my question is the following: I have sinus allergies and the side effect of this drug is nasal congestion, which complicates my discomfort. I am 66 years old and very active physically and in good general health other than the hypertension. Is it better to remain on the ace inhibitor or switch to the beta blockers or calcium inhibitors? Will these other drugs impact my life style or general health more?

Answer: There are several possibilities. First, the calcium channel blockers after ACE are usually the best tolerated. In men over 50, drugs like Hytrin and Cardura are often helpful for BP and will improve prostate function. Whether you will experience side effects will depend on your individual reaction to each drug. Usually, you have to try several to see what works with the least side effects.

Hypertension Medications
Question: My husband is taking Zestril for hypertension. He is suffering from impotence because of this medication. Are there any other alternatives that can be used?

Answer: There are many: Try beta blockers, diuretics, and calcium channel blockers in about that order to see what works with impotence. Importantly, check his blood pressure at home to see that he is not over-treated by medications(a common problem). Many patients experience a rise in BP at the doctor's office and are consequently over-treated causing side effects(like impotence).

Question: Could you please advise me how to control my high blood pressure?

Answer: Fortunately, or unfortunately, most of the treatments for blood pressure are prescription. Losing weight and cutting back on salt will help, and losing weight is the most likely to "fix" the problem long term. Short of this, you will need to see a physician for some basic blood tests, (EKG, etc.) to tailor your medications. There are over 20 different classes of drugs used for treatment of hypertension and it takes some work to find the one to work with the minimal side effects.

Question: I have been told that I am suffering from high blood pressure Could you give me some advise on how to control it?

Answer: 1. Lose weight. 2. Check your BP repeatedly prior to seeing a physician. If it is consistently over 140/90, it will need to be treated. Often weight loss will fix borderline hypertension. More elevated BP will usually need drugs which your physician will need to tailor to your individual situation.

Question: My husband is 62 and has been on vasotec for 8 weeks. there has been no change in his condition. today his read was 200/100. He checked back with the doctor about one month ago and the doctor made no comment about the lack of change in the readings. Is it time to change doctors?

Answer: Vasotec belongs to a class of drugs called angiotensin converting enzyme inhibitors. These drugs work by inhibiting the enzyme that converts renin to angiotensin. Renin is produced in the kidney and the conversion is mainly in the lung. Consequently, ACE inhibitors work great on patients with high levels of renin. However, they are nearly useless in patients with low levels of renin. As it turns out 1 of 4 caucasians and 3 of 4 blacks have low renin hypertension - that is elevated blood pressure with a low level of renin. These patients traditionally respond best to diuretics, calcium channel blockers, etc. Vasotec typically works within 24 hours-not several weeks. I'd recommend at least a different medication. It doesn't seem like your physician understands the theory behind his medications.

Young Hypertension
Question: I am an otherwise fit 35 year old male with an active sports life. I was diagnosed in 1994 with serious hypertension (which had been undetected for some time, resulting in a small degree of LVH). I have had this problem successfully controlled since that time with an Ace Inhibitor (Innovace). Can I remain on this medication forever or does it have long term toxic or other side-effects? Are there other effective agents available that might suit an active, young person better? Are there any other steps that can be taken to find a root cause (if any). I have had blood tests and kidney scans.

Answer: Hypertension is an exceedingly common disease in this country, and is not uncommonly seen in otherwise healthy, young people who are wholly asymptomatic. The first line of therapy for patients with hypertension is that of behavior and dietary modification. Cutting back on fatty and salty foods, as well as increasing physical activity, starting a regular exercise plan, weight loss, and healthy dieting, all under the supervision of your physician, can improve, if not entirely resolve some patient's high blood pressures. When diet, weight, or activity level are not an issue, as they appear not to be in your case, medication is the next step. However, hypertension can rarely be due to an underlying disease that if treated, will resolve the high blood pressure. In young patients who are otherwise healthy, testing for these disorders prior to long term medication is often warranted. Measuring certain chemicals in the blood (catecholamines) can be helpful in determining whether an adrenal gland problem is the cause, and renal scans can determine whether a renal artery problem is a factor. Your physician can discuss with you the many diagnostic options available to pursue the few rare underlying diseases that can cause hypertension, and then you both can decide on an appropriate plan.

If underlying causes are excluded, than the patient has what is known as "essential" hypertension, and appropriate medication therapy should be initiated. ACE inhibitors are an excellent choice for treatment. Although there are side effects, which include swelling, liver inflammation, excessively low blood pressure, dry cough, and low white blood counts, these are quite uncommon and the vast majority of patients do not experience these problems. Some patients do not tolerate the medication in that the mechanism by which the drug lowers blood pressure also causes high blood potassium and/or impaired kidney function in these select patients. This can and should be monitored by your physician with intermittent and regular blood chemistry checks.

There are a large and varied number of medications available to treat hypertension. "Calcium channel blockers", "Alpha and Beta Blockers", and "Central antihypertensives", are the other major classes currently in use. These also have their benefits and side effects, and it is important that patients and their physicians find the optimum balance between these based on the patients lifestyle. Discuss with your doctor other possible medications, and decide with he or she, whether any of these medication's benefits outweigh the potential side effects. And as always, discuss with your physician, any possible interactions between this medication and any others you may be taking.

Ankle & Calf Swelling
Question: My husband has been on Procardia XL for more than 5 years to control hypertension and it has worked very well up to this date. However, he has recently had problems with both ankles and the calf on both legs swelling. There is no pain associated with the swelling. If he elevates his legs for several hours, the swelling will go down some. Unfortunately, our family doctor is on vacation until August 4. Can this be a side effect of Procardia. He also is on Synthroid, Provachol.

Answer: A very common side effect of Procardia and all the calcium channel blockers(Procardia is one of the worst.)

Multiple Medications
Question:When taking the following 4 drugs for hypertension: atenolol zestoretic pravachol, and norvasc as far as time-of-day goes, should they be taken in AM or PM - all together or split up between AM and PM? Am interested in avoiding or minimizing side effects. This is a repeat query since I'm not sure if the first one was properly typed and sent to you.

Answer: Pravachol is for lowering cholesterol-not for hypertension. As to the other three, one is a beta blocker, one a combination ace inhibitor and diuretic and one a calcium channel blocker. There shouldn't be any risk in taking them together-am or pm is probably not a big issue as long as it is consistent.

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