The majority of US adults with hypertension have not achieved recommended blood pressure (BP) targets.1 One often overlooked barrier to control is iatrogenic, the use of medications that are known to raise BP.2 Given national trends of increasing polypharmacy,3 use of medications that raise BP may contribute to poor BP control rates and also worsen polypharmacy. Thus, in this cross-sectional study, we examined National Health and Nutrition Examination Survey (NHANES) data to characterize the prevalence of use of medications that may raise BP and assess their associations with BP control and antihypertensive use.
The NHANES is a nationally representative biannual survey of the US noninstitutionalized population.4 We examined 5 survey cycles (2009-2018) and included participants who were 18 years or older and not pregnant. Prescription medication use was obtained from home interviews. Antihypertensives and medications that may cause elevated BP were identified from the 2017 American College of Cardiology and American Heart Association guidelines.2 This study was considered exempt from human participants’ approval by the institutional review board at the Beth Israel Deaconess Medical Center because all data are deidentified and publicly available. All NHANES participants provided written informed consent.
Hypertension was defined as an average systolic BP of 130 mm Hg or higher, average diastolic BP of 80 mm Hg or higher, or answering “yes” to the question, “Have you ever been told by a doctor or other health professional that you had hypertension, also called high blood pressure?” Uncontrolled hypertension was defined as an average systolic BP of 130 mm Hg or higher or an average diastolic BP of 80 mm Hg or higher.2
First, we determined the prevalence of use of medications that may cause elevated BP overall and by class. Second, we constructed multivariable logistic regression models to estimate the association between the use of medications that may raise BP and uncontrolled hypertension in the full cohort, stratifying by concurrent use of antihypertensives. Third, we examined whether adults with hypertension who were using medications that may raise BP were treated with a greater number of antihypertensives by estimating separate multivariable negative binomial regression models for patients with controlled and uncontrolled hypertension (see eMethods in the Supplement for additional model details).
Responses were pooled from the 5 survey cycles, and sampling weights were used for all analyses to provide nationally representative estimates with 95% CIs. Analyses were performed using SAS, version 9.4 (SAS Institute) and Stata, version 16.1 (StataCorp LLC).
The study population included 27 599 adults (mean age, 46.9 [95% CI, 46.4-47.4] years; 50.9% women [95% CI, 50.2%-51.5%]; 11.3% Black individuals [95% CI, 9.7%-12.9%], 14.8% Hispanic individuals [95% CI, 12.6%-17.0%], 65.3% non-Hispanic White individuals [95% CI, 62.2%-68.3%]), of whom 49.2% (95% CI, 48.1%-50.4%) had hypertension and 35.4% (95% CI, 34.4%-36.6%) had uncontrolled hypertension.
In total, 14.9% (95% CI, 14.1%-15.6%) of US adults reported using medications that may cause elevated BP, including 18.5% (95% CI, 17.5%-19.5%) of adults with hypertension (Table 1). The most commonly reported classes were antidepressants (8.7%; 95% CI, 8.0%-9.5%), prescription nonsteroidal anti-inflammatory drugs (NSAIDs) (6.5%; 95% CI, 5.8%-7.2%), steroids (1.9%; 95% CI, 1.6%-2.1%), and estrogens (1.7%; 95% CI, 1.4%-2.0%).
The use of medications that may raise BP was associated with greater odds of uncontrolled hypertension among adults not concurrently taking antihypertensives (odds ratio, 1.24; 95% CI, 1.08-1.43) but not among patients concurrently taking antihypertensives (Table 2). The use of medications that may raise BP was associated with greater use of antihypertensives, among both adults with controlled hypertension (incidence rate ratio for use of 1 medication that may cause elevated BP, 1.27; 95% CI, 1.11-1.44) and adults with uncontrolled hypertension (incidence rate ratio, 1.13; 95% CI, 1.03-1.25).
In this nationally representative survey study, 18% of US adults with hypertension reported taking medications that may cause elevated BP. The use of these medications was associated with increased odds of uncontrolled hypertension among individuals not taking antihypertensives and greater use of antihypertensives among both patients with controlled and uncontrolled hypertension. Study limitations include reliance on patient self-report of medication use, lack of reporting on medication dose and duration, and omission of over-the-counter medications, leading to underestimation of NSAIDs and decongestant use.
Many medications known to raise BP have therapeutic alternatives without this adverse effect—for example, acetaminophen in place of NSAIDs and progestin-only or nonhormonal contraceptives in place of ethinyl estradiol–containing contraceptives.5 Thus, our findings indicate an important opportunity to improve BP control by optimizing medication regimens, an approach that has the potential to also reduce polypharmacy and medication regimen complexity.6 Clinicians caring for patients with hypertension should routinely screen for medications that may cause elevated BP and consider deprescribing, replacing them with safer therapeutic alternatives, and minimizing the dose and duration of use when alternatives are not available.
Accepted for Publication: October 6, 2021.
Published Online: November 22, 2021. doi:10.1001/jamainternmed.2021.6819
Corresponding Author: Timothy S. Anderson, MD, MAS, Division of General Medicine, Beth Israel Deaconess Medical Center, 1309 Beacon St, Brookline, MA 02246 (email@example.com).
Author Contributions: Dr Vitarello had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Vitarello, Fitzgerald, Cluett, Anderson.
Acquisition, analysis, or interpretation of data: Vitarello, Fitzgerald, Juraschek, Anderson.
Drafting of the manuscript: Vitarello, Fitzgerald.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Vitarello, Fitzgerald.
Obtained funding: Anderson.
Administrative, technical, or material support: Cluett, Anderson.
Conflict of Interest Disclosures: Dr Anderson reported receiving honoraria from Alosa Health, a nonprofit educational organization with no relationship to any drug or device manufacturers, related to deprescribing education, outside the submitted work. No other disclosures were reported.
Funding/Support: Dr Anderson was supported by grants from the National Institute on Aging (L30AG060493 and R03AG064373), American College of Cardiology, and Boston Claude D. Pepper Older Americans Independence Center. Dr Juraschek was supported by grants from the National Heart, Lung, and Blood Institute (K23HL135273).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension
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