Blood pressure meds and ibuprofen

[george carr]

Just wanted to put this out there for those of you taking blood pressure medications. I recently led a group on an overnight on the AT in MA. Everything was going fine until the last 2 miles heading into Salisbury, when one of the members of the group named Paul started having trouble walking (calve pain, sore legs, low energy). Dehydration was suspected, and in the last 1/2 mile or so he could only take about 5 steps before needing to rest (with no pack!). We got Paul into town (that's right, no SPOT rescue :p)and fed him and gave him water and gatorade, and he felt better on the way home.

The next day I spoke to him briefly around noon and Paul said he felt better, but by 4pm he was admitted to the hospital with renal failure. Apparently the doctors say he created the "perfect storm" of stress from hiking, dehydration, and mixing blood pressure meds with vitamin I, which brought on his kidney failure. Here we are one month later and his kidneys have finally restarted. He gets his catherter out hopefully Tuesday, and he hasn't needed dialysis for 5 days.

If I had to place a bet before the trip who would have problems Paul would not have been on that list at all. He has run marathons and backpacked before, and is generally in good health. The biggest mistake he made (other than mixing meds) was to not tell anyone he was having a problem until it was too late.

I only put this out there so that others using blood pressure meds will check their particular prescription for drug interactions, as not all BP meds act this way.

[Derek Goffin]

can you tell me what his exact prescription was? I am on Ramipril.

[John S.]

Ibuprofen Oral (from WebMD)

Who should not take this medication?

Check with your physician if you have any of the following:

Conditions:

Tobacco Smoking, Increased Cardiovascular Event Risk, Time Immediately after Coronary Bypass Surgery, High Blood Pressure, Chronic Heart Failure, Disease of the Heart and Blood Vessels, Painful, Red or Swollen Mouth, Stomach Ulcer, Ulcer of the Duodenum, Ulcer from Stomach Acid, Stomach or Intestinal Ulcer, Liver Problems, Bleeding of the Stomach or Intestines, Kidney Disease, Pregnancy, Blood Clotting Disorder, Habit of Drinking Too Much Alcohol

[Brian Barnes]

Derek – Not sure what the person in the first post was taking but it was likely an ACE inhibitor like your ramipril (Altace). NSAIDs such as naproxen, ibuprofen, etc can certainly cause renal failure in those who are dehydrated and concomitantly taking ACE inhibitors.

The drug interaction has an interesting mechanism. Simply put (I'll spare you the technical details), the kidney needs higher blood pressure in its "outlet" than its "inlet" to create a pressure gradient. This pressure gradient (higher pressure in the outlet – lower pressure in the inlet) is needed for urine formation.

ACE inhibitors decrease the pressure in the "outlet" (via vasodilation) and NSAIDs increase the pressure in the "inlet" (by reducing production of vasodilating substances). These two effects effectively reverse the pressure gradient in the kidney preventing it from producing urine. If you add dehydration to the mix, blood perfusion to the kidney is already impaired and this significantly increases the risk of renal failure.

In someone who is hydrated sufficiently, short term use of NSAIDs with ACE inhibitors is usually tolerated. But like Dr. Shannon suggests, check with your physician before doing so. Its also a good idea to stay hydrated, watch your urine output/color, and keep an eye on your body weight.

[Sarah Kirkconnell]

Yes, very, very bad for those on ACE inhibitors!
Go to this site http://www.nlm.nih.gov/medlineplus/druginformation.html and look up EVERYTHING you take. Read the notes for doctors as well.
Blood pressure pills may do wonders but they can do very bad things if one doesn't know side effects (it is beyond belief how doctors don't tell patients these things!)
Read, read and read some more.

I only take Tylenol and only if I am in super pain. I take NO supplements (outside of vitamins).

As well, if a person gets dehydrated while on BP meds your BP can actually go down, very down.

[douglas girling]

Thanks – there is some very good information here. I agree NSAIDS, ace inhibitors and dehydration do create a perfect storm for the kidneys. (Just make sure you don't create a perfect storm for the liver though by taking excessive amounts of Tylenol. Tylenol is very good at the recommended dose but exceding this recommended dose can be catastrophic for your liver. I've seen too many unfortunate cases of this in our ED)

I too like Tylenol myself for generalized aches and pains. If I do have a localized injury that I think may benefit from NSAIDS I have had great success (anecdotal) with topical Voltaren (diclofenac) It really helps local inflammation and has limited systemic absorbtion (I have no personal financial interests in Voltaren) but just though I'd throw it out there as a possible option.

doug

[Brian Lewis]

I take blood pressure medication (Lisinopril) and took some ibuprofen and was no doubt dehydrated along the PCT last year. Had no problem that I know of, but I very much appreciate this warning. As a result, I'll take "Vitamin I" out of the set of stuff I carry, and replace it with a mix of Tylenol and Tylenol PM (maybe I should have a careful look on the label of that latter stuff too …).

I was never the type to pop ibuprofen like candy, always inclined to take less rather than more. But in fact my doctor suggested Aleve (Naproxen Sodium) as something to take for a foot issue I had, and I see it also prominently listed as something that my BP medication can interact with.

Regardless of what the odds of such a "perfect storm" might be (likely hard to calculate), switching to Tylenol doesn't have much of a downside. And, of course, taking as little of it, too, as seems really needed.

So thanks!

[Brian Barnes]

This thread reminds me of an old pharmacology professor I had in school who said "drugs are toxins with therapeutic side effects"…

FWIW here is a list of some ACE inhibitors. I'm sure there are others but these are most of the US approved ACEIs:

Benazepril (Lotensin)
Captopril (Capoten)
Enalapril(Vasotec)
Fosinopril (Monopril)
Lisinopril (Zestril and Prinivil)
Moexipril (Univasc)
Perindopril (Aceon)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril (Mavik)

This same drug interaction can occur with another similar drug class for hypertension called Angiotensin II Receptor Blockers (ARBs). Here's a representative list:

Candesartan (Atacand)
Eprosartan (Tevetan)
Irbesartan (Avapro)
Telmisartan (Mycardis)
Valsartan (Diovan)
Losartan (Cozaar)

When used appropriately all drugs (well most) are useful. Just be an advocate for yourself and use the resources that are available to you (self education that is confirmed by providers – physicians, pharmacists, etc)

[Derek Goffin]

When you Americans mention Tylenol do you mean aectaminophen, what we Brits call paracetamol?

[george carr]

Sorry folks, I should have gotten the name of the BP meds before posting. I'll find out which one it was when I speak to Paul this week. FWIW, the guy is a drug company rep and it caught him by surprise too. Apparently he hasn't had side effects from his meds and vitamin I before (lucky maybe?).

[Brian Lewis]

"When you Americans mention Tylenol do you mean acetaminophen, what we Brits call paracetamol?"

Yes:
http://en.wikipedia.org/wiki/Tylenol

[Sarah Kirkconnell]

The issue with ANY pain killer is being too dependent on them. For anyone, the less you take the better.

Rate pain by how you can function before taking pills. Soreness sucks but you can live with it. Where as a blinding bad migraine you need it to hike out. Take 1 pill, not 2. Take them every 8 to 12 hours versus every 4 to 6 hours.

I remember years ago I was on a BP pill where I was to AVOID potassium. Very hard to control leg cramps in hot weather I can say…when you can't eat bananas or potato chips. Then again, how many users of that pill even had been told that bit of info?

[Kattt]

Reducing digital footprint

[backpackerchick]

Buyer beware. Dx of "borderline hypertension" has increased this market dramatically. $$$ Give serious consideration to just how high your BP is and the risks associated with the drugs. Do you really want to take this stuff?

Old and cheap. Recent large studies have shown thiazide diuretics to be as effective as the blockbuster ACE inhibitors. No money in them though.

Was this guy in ARF taking statins too?

[Roger Caffin]

+N on what Hartley says. The drug industry is focused on your wallet, not your health.

Cheers

[Sarah Kirkconnell]

I call BS on that. If someone had put their foot down to my mom in her 20-40's and said "Your uncontrolled borderline BP can lead to renal failure" she would have listened.

Yes folks, uncontrolled BP can and does lead to fun things like renal failure and more. It contributes to heart disease, risk of stroke and heart attacks.

My mom was not put on strict controls until her 50's and by then all the damage was in line. My mom suffered renal failure, survived a coma from it – which I might add she went into it on a freaking ferry in my car – and then lived by having dialysis twice daily for 7 years. My mother died of a heart attack after having 2 small ones back to back – her body was so worn down from the renal failure. The root was that pesky BP in the end.

My father as well died young, in his early 60's (my mother was barely 60) due to heart and circulation issues directly attributed to his under controlled BP. Again, as with my mom he had been allowed by Doctors to have 150 to 160 on top and no one seemed concerned.

When my father passed away the hospital asked us for permission to do an autopsy as they had tried everything to save him and couldn't. My brother signed on it and frankly, I am glad we did. The coroner's advice was that if we wanted to avoid their fates to control our BP tightly and ALWAYS. My brother and I have had borderline BP since we were teens – it is a genetic thing after all in many families.

Diuretics are the base choice in many cases but can also mess you up bad. They can cause severe dehydration as well as stripping your body of minerals – so again, ask questions! DO NOT go hiking or backpacking on them until you know HOW you react to heat and stress. Stay hydrated!!

(I cannot take diuretics. They cause rapid heart rate in me.) I am even taking my pills while pregnant (of the few considered fetus safe.) They are letting my BP be a little higher without worrying but keep it tuned to no more than 140/90.

It isn't anything to take lightly!!!! You are talking about your health 20 to 50 years from now people!

[backpackerchick]

SBP 160 is not borderline.

Drastic lifestyle changes can go a long way despite genetic predisposition. There's no $ in lifestyle changes though.

ACEI /ARB market is extremely lucrative and definitions of illness are being tweaked to include ever greater numbers of people. And Big Pharma is pushing off label use harder than ever. The net is being cast wider and wider.

[Sarah Kirkconnell]

Genetic BP issues is something you don't beat through exercise or even diet. That is BS in many ways.

The best I can get away with even when in very good shape is taking the minimum dose. I will NEVER be BP med free. It is not possible. I live on a low sodium diet, do not smoke, don't use oral BC, don't drink, exercise and live a healthy life. Yet I will always have high BP without meds. That is a fact of life for many people. It isn't obvious either – the reason why it is called a silent epidemic.

Borderline at 140/90 for many doctors in the US – this is when they start watching it. 120/80 or 130/80 is better. Better to start on meds than let it go and in 20 years have issues that cost dear.

But hey, you are entitled to what you want. Me? I'll do what it takes to keep my BP where it needs to be. Not like the drug companies are making money off of me though – I take a generic old school drug that costs me $4 a month. Ooh, big profits there. Not.

[Michael Williams]

I feel like I should come to the defense of ACE inhibitors and ARBs. They have side effects for sure, so do all drugs. They also have extra benefits a diuretic doesn't have for patients with other disease states.

The decision to take medication for high blood pressure and what medication to take should hopefully be a decision made by both your doctor and yourself taking into account your situation.

[backpackerchick]

May be somewhat reno-protective in diabetes independent of anti-hypertensive effect. The jury is out. But at what cost?

Benefits probably outweigh the risks in some patient populations. The main beneficiary though is big pharma. Personally, wouldn't touch the stuff until I had eliminated all animal products, salt (other than traces plants soak up in soil) caffeine, alcohol and nicotine and achieved a BMI of 20. And relaxation techniques. Others must decide their threshhold.

Part of healthcare reform in the US should be to get big pharma advertising off TV!

[Roger Caffin]

> Part of healthcare reform in the US should be to get big pharma advertising off TV!

As far as I know, America is the only country in the world where Big Pharm is allowed to advertise direct to the public.

Cheers

[Mary D]

The HMO for which I used to be an accountant had big problems with people coming in to the doctor's office demanding the drugs they'd seen advertised on TV. Drug costs started heading for the upper stratosphere as soon as the TV advertising started.

You really have to be a physician (or a veterinarian) to appreciate how much the big drug companies spend wooing the medical professions. My daughter is a veterinarian and her husband is a physician; they both were horrified when they got into medical/veterinary school and discovered how much the drug companies were lavishing on the students.

I suspect that proprietary drugs would be a lot less expensive if Big Pharma were forced to cut its advertising!

This is way off-topic, though! Back to the original topic: Thank you for the warning! It behooves all of us to track our medications–which include over-the-counter medicines–to make sure there won't be any interactions. Not all physicians do this when prescribing–it is up to each of us to keep track of our own. We also need to let our physicians know what over-the-counter items we take–even vitamins can be important! And we need to tell them about our activities, too.

[backpackerchick]

Roger, New Zealand too. I think that's it.

When tobacco advertising was banned in the US, it freed up a lot of big time marketers (and lobbyists for that matter). Using the same tactics to push pharmaceuticals. There are several good books out there on the situation. Marcia Angell's is excellent. This is an industry that has bought off its end consumers, physicians, legislators and regulators. And nowhere does it play out bigger than in for profit US healthcare.

Let's not even talk about the risk of Plavix in the backcountry.

[Michael Williams]

Off topic, and not to be inflammatory, but the benefits of ACE's and ARBs in diabetes has been clearly demonstrated in large scale trials. Fortunately here in Australia they aren't very expensive although in other countries I can imagine cost becoming an issue.

[backpackerchick]

Not the same. Hard to incorporate the morbidity due to side effects. Also must consider who sponsored the study. Even taken in the best possible light, results look pretty whimpy to me. What ever happened to lifestyle changes and addressing other risk factors.

This patient population is often on numerous other drugs. Statins and ACEIs? There's some potential for renal implications. (Add a bit of myoglobin to that pressure differential.) And let's put a bit of metformin in the mix for good measure.

There is another way! Just no pills to sell. Or first class airfare to the next overseas conference (big crackdown on this in US though). Or big pharma "consulting" fees. Physicians considered "thought leaders" can reap up to US $1 million/year from drug companies. Got to look at the patient as a person not just a blood glucose level or a SBP.

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