THE PEOPLE’S Graedons’ Guide to PHARMACY

GRAEDON ENTERPRISES, INC www.peoplespharmacy.com Treatment

igh blood pressure has been units of mm Hg. The systolic is first and High Blood Pressure dubbed the silent killer. In many the diastolic second: 120/80, etc. cases, the onset is gradual, and Now, think about a garden hose and High blood pressure is a Hsince there are often no symptoms, it may imagine that the water is just pouring out very serious health con- also be unsuspected. The trouble is, untreat- without much pressure. To get a strong cern that affects roughly ed (high blood pressure) can flow, you need a nozzle to narrow the 65 million Americans, or lead to serious consequences over the long opening. The smaller the nozzle, the almost one in three adults. term. People with elevated blood pressure farther and harder the water will shoot. Another 70 million of us are more likely to develop Blood vessels operate in similar ways. are “prehypertensive.” and kidney disease, and they run more risk When the diameter narrows, as it does Odds are that you’re in of both strokes and heart attacks. Getting under stress or excitement or as a con- one or the other of these the pressure down reduces the likelihood sequence of atherosclerosis, the pressure categories. High blood of experincing such catastrophes. increases. If it gets too high, organs such pressure is the chief risk At the danger of oversimplification, it as the brain, the heart, or the kidneys factor for strokes, heart may be helpful to think about blood pres- may suffer. attacks, atherosclerosis, sure in terms of plumbing. Think of the Blood pressure can vary significantly kidney damage and de- heart as a pump with hoses connected to throughout a normal day or week—by as mentia. It’s also not well it. Each time it contracts to squeeze blood much as 50 points over the course of 24 controlled in the vast ma- through the system, pressure in the hoses hours. Exercise or agitation makes it rise; jority (more than 70%) of reaches a peak, called the systolic pressure. meditation or sleeping usually makes it those who suffer from it. As it relaxes, the pressure lets up. That’s drop. The levels at which a doctor decides that blood pressure requires treatment called diastolic pressure. Because early pressure-measuring devices used a column are somewhat arbitrary, and may be dif- of mercury, blood pressure is expressed in ferent from one doctor to the next. WHITE COAT HYPERTENSION White coat hypertension is the medical term for a reaction some people have to the approach of a doctor or nurse with a blood pressure cuff. The pulse may quicken and blood pressure soar 20 or more points right in the doctor’s office. The best study of this was done some years ago in Italy with equipment that took extremely accurate, continu- ous blood pressure measurements on 48 hospitalized people. When a physician entered the room to take blood pressure with a traditional cuff and stethoscope, 47 out of 48 patients experienced an increase. The average rise was 27 points, but one reading spiked 75 mm. Even people with normal blood pressure had elevations. How many people are affected by white coat hypertension? Some experts estimate that 15 to 30 percent of patients diagnosed with high blood pressure may have a problem only in the doctor’s office. Older people may be especially vulnerable. White coat hypertension is controversial. Some physicians believe that it should be treated aggressively, on the grounds that any stress may make blood pressure rise excessively in someone who experiences it. They reason that if a person has hypertension in the doctor’s office, he or she may respond in a similar way to a disagreement with the boss, an argument with a spouse, or a close call in traffic. Other doctors fear that white coat hypertension may lead to false diagnoses of disease, as our blood pressure is constantly changing throughout the day and week. Being labeled “hypertensive” is enough to affect self-image, work productivity, and general well being. It may also result in unnecessary medication. We encourage people to acquire an easy-to-use home blood pressure monitor and to keep a diary of readings to be shared with their health care provider. This way, they can measure their blood pressure under a variety of conditions (work, stress, relaxation, etc.), which can help determine the most appropriate treatment strategy.

© 2008 Graedon Enterprises, Inc. Are You Angry? Dos and Dont’s of Managing Blood Pressure Drs. Redford and Virginia Wil- liams wrote a fabulous book several years ago called Anger • Measure your blood pressure at home Kills. Their work reveals that hostility is bad for the heart. • Monitor your stress level There’s also confirming • Practice relaxation evidence from Canadian re- • Lose weight searcher J. David Spence, M.D. • Try the DASH diet that people who react to stress and frustration with elevated • Don’t forget your minerals blood pressure may be more • Drink pomegranate, beet, and grape juice likely to develop atherosclero- • Breathe easy with RESPeRATE sis than people who take life’s curveballs in stride. These “hot • Keep in touch with family and friends reactors” may be at least as • Stay away from coffee, licorice, and blood pressure-raising drugs vulnerable to hardening of the • Beware the beta-blocker blues as people who smoke or have diabetes. Dr. Spence • Talk to your doctor about cholorthalidone believes that people who over- • Remember your ACE in the hole react to stress may be a lot like hostile and cynical folks who are also at greater risk of heart • Avoid talking attacks and strokes. Home Monitors If you’re someone who tends Doctors and nurses often like to chat with to feel stressed or angry when There are many blood pressure monitor- patients during readings because they you’re cut off in traffic, your ing devices on the market, ranging from think it will help calm us down. Research spouse is late for dinner, or a an old-fashioned mercury sphygmoma- suggests, however, that they may elicit the person in the express lane at nometer with a stethoscope to a machine opposite reaction: a measurement taken the supermarket has too many with a digital read-out. Some devices are during conversation could be artificially items, you might want to think even self-inflating, making it possible for high (more than 20 points!). Try to sit about learning to recognize and anyone to take his or her own blood pres- quietly for 5 minutes before your blood monitor your tense reactions, sure without assistance. pressure is taken. as they could be negatively We have been especially impressed affecting your health. with the Omron products. They are easy to use and reliable, and were highly rated • Maintain correct body position Measuring Stress by Consumer Reports. The model that was Your arm should rest on a flat surface that’s most highly rated is Omron Automatic at about the same level as your heart, like If you lived through the 1970s, you probably remember the BPM with Intellisense. It also has a nice, a desk. If your arm is in your lap, both mood ring craze. Silly as it may large cuff that should fit most people, and your systolic and diastolic numbers will be sound, mood rings (or their its memory recall will make it easy to keep higher. Also be sure that your back is sup- newer, higher-tech cousins) track of your readings over time. It’s a little ported. Sitting on the exam table could add might provide a good visual cue pricey at $80 to $90, but Omron also makes as many as 5 points to your reading. for rising stress levels that could a ReliOn line which is a bit less expensive. signal elevated blood pressure. It’s available at Wal-mart for about $40 to • Keep a diary Mood rings are still readily avail- $60. To find a store that sells them in your able. (See www.moodjewelry. area, go to www.omronhealthcare.com, or There is enormous variability in blood com.) But we’re even fonder of pressure throughout the week and even the slightly more sophisticated call Customer Service at (800) 634-4350. Bio-Q Thermal Biofeedback the day. The numbers that get recorded in and Stress Monitoring Ring at To Get An Accurate Reading your chart are only one tiny sliver of your www.futurehealth.com. And if blood pressure story. For that reason, it’s you don’t like rings, there are Make sure you and your doctor: important to take blood pressure read- Bio-feedback Bio-Squares, liq- ings at various times of day and under uid crystal “chips” smaller than • Use the proper cuff size as many different conditions as possible. stamps that stick to your skin. A cuff that’s too small could falsely elevate Keep a careful record of your readings Like the rings, they change col- and of what you were doing before and ors as your body temperature your readings. Request the right cuff size during each measurement. That will help (and mood) changes. You can at the doctor’s office. And if you need a find them on Amazon for about larger cuff at home, Omron makes them you note trends that you can then share $15 per 100. in a variety of sizes. with your physician.

2 Non-Drug Options Exercise sensibly Chocolate There are literally dozens of medications for If you are out of shape, never start exercis- Hard as it may be to believe, high blood pressure on the market, and while ing without first checking with your health chocolate can actually be pharmaceuticals may indeed be the only option care provider. Overdoing it, especially in good for your health. It’s full for some people, all of these pills can cause the beginning, is the path to disaster. One of the same antioxidant fla- side effects, sometimes very serious ones like study revealed that people who were out vonoids found in red wine and potassium depletion. of shape and unprepared were 100 times green tea—in fact, cocoa and We think it can’t hurt to try some non-drug more vulnerable to a heart attack if they chocolate have even more of options first. Remember, though, that it’s ex- suddenly started to exercise vigorously. the good stuff, as well as other tremely important to communicate with your Shoveling snow or running to catch an air- compounds that help the heart physician at every stage about blood pressure- plane can trigger serious heart problems. and cardiovascular system. lowering strategies. Managing hypertension Pick an activity that you enjoy. That One long-term study showed requires careful medical supervision. way you are more likely to stick with it. that Dutch men who ate about Walking is excellent, especially if you can 10 grams of chocolate a day Watch your weight do it for 30 to 60 minutes at least four days (the size of a Ghiradelli square) a week. Whatever exercise you select, keep had lower systolic pressure by Losing as little as 10 or 15 pounds can it up. The buddy system can be a great 3.7 mmHg. Their chances of make a big difference in your blood pres- motivator if your friend encourages you. dying of heart disease were sure. Overweight people who shed about Make sure to put your exercise times on also decreased by 50%. 18 pounds can expect their systolic blood the calendar as if they were important Go ahead and try a little pressure to drop by 8.5 mmHg and their appointments. Fitness will improve and chocolate—the taste (and diastolic pressure to come down by 6.5 weight loss will follow. rewards) are sweet! If you’re mmHg. That’s about what you could watching your blood sugar or hope for if you were to go on medication. Eat, Drink and Be Merry calories, you could go for cocoa Of course, losing weight may be difficult, without sugar, like Scharffen but it is well worthwhile in terms of self- The DASH Diet Berger or Valrhona (not alkali esteem and general health. or Dutch-processed). The experts tell us that many people Designed specifically to help control munch when they are bored, anxious or hypertension, the DASH diet has been upset, and that this contributes to uncon- studied extensively and demonstrated Special Foods scious calories that can really add up. A to be effective. It brings systolic pressure Although the jury’s still out on food diary is a good way to review when down by an average of 11.4 mmHg and whether or not garlic and onions you are eating and why. The very act of diastolic by 5.5 mmHg. The basics are really lower blood pressure as writing down every bite can make you daily intake of: many people claim, it certainly more aware of your mental state and en- • 4 servings of fruit can’t hurt to try adding them courage alternative activities for relaxation • 4 servings of vegetables fresh to your diet. Be care- or relief of boredom. • 7 to 11 servings of grains ful about garlic supplements, Sensible eating usually means less • 2 to 3 servings of low-fat dairy foods though: they may interact with and more fresh fruits, vegetables and • Nuts, fish, and poultry some medications to increase whole grains. We especially recommend • Little red meat, sweets, and sugary the risk of bleeding. the DASH (Dietary Approaches to Stop drinks Another food some folks Hypertension) diet (see right), but keep For $8, you can get more specifics from swear by is celery. Again, in mind that different programs work for the book The Dash Diet for Hypertension, or there’s no scientific evidence different people. And of course, portion for free, you can get an overview at: www. to prove it can fight hyperten- control is important, too. One trick we nhlbi.nih.gov/health/public/heart/hbp/ sion, but it’s worth a try. The like when we eat out is sharing the entree. dash/new_dash.pdf. “dose” is eight ribs a day; do If your dining partner is willing, this can Remember, though, that other diets may an experiment and record your halve your restaurant calories. work just as well. In fact, research from blood pressure readings to see The other component of a weight loss Johns Hopkins suggests that replacing if you notice a change. program is to increase the energy you use. some of the carbohydrate calories in the Some other foods may block Engaging in regular, moderate exercise DASH diet with protein or monounsatu- angiotensin-converting en- can help bring down blood pressure by rated may be even more effective for zyme just like the ACE-inhibitor at least 2 or 3 mmHg. For starters, try lowering blood pressure and . class of drugs: compounds in parking a little farther away at work or Choose the diet that’s right for you—South aged gouda and fermented milk the shopping mall. Beach, the Zone, or something else that products like kefir, which you better fits with your lifestyle. can get in health-food stores.

3 Maximize Your Minerals the angiotensin-converting enzyme, thus lowering blood pressure. It can reduce High Magnesium Minerals can make a difference for blood ACE activity by roughly 36% percent, and Foods pressure and heart health. Calcium, mag- one study found that subjects who drank nesium and potassium are especially 2 ounces of it daily brought their systolic Halibut, 3 oz (90 mg) important. While the individual effects pressure down by about 8 points. Almonds, 1 oz (80 mg) of each of these electrolytes on blood Cashews, 1 oz (75 mg) Pomegranate juice also benefits the pressure is relatively small, studies have Soybeans, ½ cup (75 mg) cardiovascular system in other ways, by Spinach, ½ cup (75 mg) shown that together they can have a signif- reducing the risk of blood clots and im- Mixed nuts, 1 oz (65 mg) icant impact. Of these three, magnesium proving blood-flow and oxygen delivery to Shredded wheat, 2 (55 mg) may be the most essential, in part because the heart. It also lowers total and bad LDL Oatmeal, 1 cup (55 mg) it’s often lacking in our diets. This is often cholesterol. In general, the juice from these Baked potato (50 mg) especially true for those on diuretics, as tiny seeds seems to create big results. Peanuts, 1 oz (50 mg) these drugs can deplete people’s systems Black-eyed peas, ½ cup (45 of magnesium (and potassium). Concord Grape Juice mg) Get your minerals from food if pos- Yogurt, plain skim, 8 oz (45 sible. Taking supplements could result And finally, purple grape juice may be mg) in an overdose, but that is difficult when another blood pressure-lowering beverage. Brown rice, ½ cup (40 mg) In one study, it brought systolic BP down by Lentils, ½ cup (35 mg) eating fruits and veggies. As an extra ben- about 7.2 points and diastolic by 6.2. Grape Avocado, ½ cup (35 mg) efit, you are more likely to get adequate Banana (30 mg) amounts of folic acid, which is helpful juice can also lower cholesterol, improve recommended: 250-500 mg for the heart. blood vessel flexibility, and decrease the For a list of magnesium-rich foods, risk of blood clots. The suggested amount *Derived from data from the see the sidebar to the left. Foods high in is about two glasses per day. Grape juice Office of Dietary Supplements potassium include: apricots, artichokes, has a lot of sugar and calories, though, so of the National Institutes of asparagus, bananas, beets, bell peppers, we don’t recommend it to those watching Health. blackstrap molasses, broccoli, brussels their weight or sugar intake. sprouts, buttermilk, cabbage, cantaloupe, THE DIRT ON SALT carrots, cauliflower, chicken, fish, kidney Socialize and Be Merry beans, lentils, lima beans, nectarines, oat- One very pleasant solution to the prob- If you have high blood pressure, meal, onions, oranges, peaches, plums, lem of hypertension is to maintain close you’ve probably been told for pomegranates, potatoes, prunes, raisins, ties to family and friends. Loneliness is years to avoid salt. But despite raspberries, wheat germ, and yogurt. a risk factor for high blood pressure: it the ubiquity of this advice, the can raise readings by up to 30 points. It data on salt are mixed. One Beet Juice may also contribute more to cardiovas- major study conducted in 2006 cular disease than even obesity or lack seemed to indicate that those New research out of England suggests that beet juice may be at the vanguard of of exercise. Isolation can strike those of who consumed less sodium retirement age especially hard; at least 9 were actually at a higher risk for the blood pressure battle. Volunteers in a study were given either two cups of beet million Americans over the age of 50 are fatal heart attacks and strokes. believed to frequently feel lonely. Nurture This doesn’t mean everyone juice to drink or two cups of water. Those who drank the beet juice experienced your social networks, and try creating new should go wild with salt; it does ones: volunteer work, art or dance classes mean, however, that assidu- about a 10-point drop in blood pressure readings, and the effects lasted for a whole and bringing home a new pet are ways to ously avoiding salt may not ben- maintain a sense of connection. efit longevity as much we’ve all day. These results are as good as those you been told. We encourage you to could expect from many drugs. eat salt with moderation, espe- If you don’t have a juicer and you’re Learn to Relax cially if you’re salt-sensitive. But having trouble finding beet juice in your Relaxation, whether you get it from listen- your quality of life doesn’t have local health-food stores, you can always ing to soothing music or petting the family to suffer entirely, either. order it online. Some retailers to try are cat or dog, is one of the most delightful and www.truefoodsmarket.com or www.luv- effective ways of lowering blood pressure. Emmett Miller’s Tapes lijuices.com, but there are many others. So many Americans are living in the fast available from: lane that lots of people have forgotten how www.drmiller.com Pomegranate Juice to relax. Biofeedback can be helpful for Or by calling: If you like sipping juice but hate beets, folks with high blood pressure. Another 800 528-2737 there are some other liquid alternatives for approach is listening to relaxation tapes, fighting hypertension. Pomegranate juice such as those from Emmett Miller, M.D. Try acts sort of like an ACE inhibitor to block “Down with High Blood Pressure.” 4 caffeine metabolizer. Slow metabolizers Breathe Easy seem to be at considerably higher risk RESPeRATE This may sound obvious, but learning to of heart attack—the more caffeine they Available at: breathe deeply and well can really reduce consume, the higher the risk. It’s hard to www.resperate.com blood pressure. It’s harder for some people be certain what kind of metabolizer you to do than you might think. One way to are, so we advice cautious consumption or bone up on your breathing technique is of caffeine for all those with blood pres- 877-988-9388 to try meditation or yoga. sure concerns. If yoga’s not for you, though, another And it may not only be caffeine that’s a amazing method is to practice breathing problem. A large study of nurses showed with a machine called RESPeRATE. It that those who drank soda (diet or regular) consists of a chest strap, a set of earphones, had a higher rate of hypertension. The re- Dietary Supplements and a computerized device about the size searchers didn’t think caffeine in the sodas There isn’t a lot of hard of a thick paperback. Initially, you breathe was responsible, but most likely something evidence to suggest that into it normally so that its sensors can learn else (as yet unidentified). It’s probably also supplements can dramati- your breathing pattern. But eventually this wise, then, to go light on the cola. cally reduce blood pressure, breathing “coach” uses melodious tones Green or oolong tea might make a very but there’s some data that to prolong your exhalations. Ideally, you good substitute for coffee and soda: they seem to indicate coenzyme want to get down to 10 breaths per minute. appear actually to lower blood pressure. Q10 might be somewhat ef- Studies have shown that RESPeRATE can fective. Another supplement decrease blood pressure by at least 5 points, Licorice that may prove beneficial, and perhaps by as much as 10 or 15. especially for those who are Black licorice may sound like a surprising But one downside is that RESPeRATE prehypertensive, is grape culprit for hypertension, but this tasty treat requires a significant time commitment— seed extract. In one study, can really throw your metabolism out about 15 minutes per day at least four or subjects taking it saw a of whack, imbalance hormones, deplete five times a week. It’s also quite pricey 12-point drop in systolic BP potassium—and elevate blood pressure (around $300), so you shouldn’t invest in and an 8-point decrease in significantly. So if you’ve been heavy- it unless you’re ready to use it regularly. diastolic. handed with the Good & Plentys, it might And exercise will likely work at least as be time to lay off a bit. well. Quit Smoking Pain Relievers and NSAIDs Pain relievers can also pose a risk. The Too obvious to belabor. And of course, this entire class of NSAIDs (nonsteroidal will make breathing deeply much easier. anti-inflammatory drugs) can elevate One caution, however: we are a bit leery of blood pressure, and over-the-counter pain Preparation H and stop-smoking drugs like Chantix, as they medications can also be a problem. High Blood Pressure seem to produce a host of negative side effects that worry us, including depres- Preparation H After using Preparation H sion and suicidal ideation. When you do for several days, my blood make the decision to quit, work with your You may also be surprised to learn that pressure went to 206 over doctor and loved ones to come up with a this popular medication can 98 and I ended up in the plan that you can stick to. lead to elevated blood pressure. It contains emergency department for the decongestant phenylephrine, which hours. Other Things to Avoid constricts swollen blood vessels. There Later that week I read in are warnings on the packaging not to use your column that someone Coffee and Soda Preparation H if you’re taking blood pres- else had experienced the sure medication, but one of our readers had The relationship between caffeine and same problem. My doc- some very unpleasant episodes before he hypertension isn’t necessarily straightfor- tor was skeptical, to say discovered the fine print. ward. While some research suggests that the least, so I lent him the as little as a cup of coffee can modestly clipping. increase blood pressure, it may not be a Other Medications I never had high blood problem for all people. Those who should There are hundreds of other medications pressure before in my life. watch out, however, are folks who me- that can make it difficult to manage blood It was always around 130 tabolize caffeine slowly. If you find that pressure. Be sure to speak with your physi- over 65. the cup of coffee or can of soda you drank cian about all of the prescription and OTC in the afternoon can keep you tossing and pills that you’re taking, and to always read turning at night, you’re probably a slow the information provided for each. 5 susceptibility to sunburn, blurred vision Diuretics Diuretics and headache have been reported. (potassium wasting) Potassium wasting Interactions: Please check with a Bumex bumetanide Diuretics (“water pills”) have long been pharmacist and physician if you combine Diachlor chlorothiazide considered a first step in treating high a diuretic with other medicine. NSAIDs Diucardin hydroflumethiazide blood pressure, as they’re extremely safe such as Advil, Aleve, aspirin, Indocin, Diuril chlorothiazide and effective. When first introduced, they Naprosyn, Orudis, Relafen or Voltaren may reduce the effectiveness of diuret- Edecrin ethacrynic acid started a revolution in hypertension treat- ics. This could be especially dangerous Enduron methyclothiazide ment, and they were once among the most prescribed drugs in the world. But as if someone were taking Lasix or Bumex Esidrix hydrochlorothiazide beta-blockers, calcium channel blockers, for heart failure. Exna benzthiazide ACE inhibitors and angiotensin receptor Other drugs that may interact with HydroDIURIL hydrochlorothiazide blockers came on the market, physicians diuretics include colestipol (Colestid), Hygroton chlorthalidone started to overlook diuretics. cholestyramine (Questran), lithium (Es- Lasix furosemide Then in 2002, some remarkable results kalith, Lithobid, etc.) and oral diabetes Lozol indapamide from the government-sponsored study medicines (DiaBeta, Diabinese, Glu- cotrol, Orinase, etc.). Laxatives may Oretic hydrochlorothiazide ALLHAT (the Antihypertensive Treat- ment to Prevent Heart Attack Trial) shook deplete the body of potassium, which the cardiology world. ALLHAT followed could be dangerous in combination with 40,000 patients for several years to test potassium-wasting diuretics. the efficacy of various blood-pressure- Digoxin (Lanoxin) is commonly pre- lowering drugs. Researchers discovered scribed with diuretics like furosemide Symptoms of that perhaps the most effective medica- (Lasix). But if potassium levels drop potassium depletion: tion for controlling blood pressure was below normal, this could become a life- (normal potassium range = 3.5 chlorthalidone, an inexpensive diuretic. threatening situation. to 5 mEq/L) Diuretics do have some disadvantages, Potassium sparing though. For one thing, they deplete the • Muscle cramps body of two essential minerals, potassi- In order to counteract the potassium- • Difficulty breathing um and magnesium. If these electrolytes depleting properties of some thiazides, • Confusion drop too low, a person may experience diuretics were developed that pre- • Mood changes disrupted heartbeat or cardiac arrest. serve potassium. Amiloride (Midamor), Aldactone • Lethargy, fatigue That is why periodic blood tests are cru- spironolactone ( ) and triam- terene (Dyrenium) are prescribed alone • Weakness cial. Eating potassium-rich foods (listed on page 4) should help lower this risk. or, even more commonly, in combination • Dry mouth, thirst Cholesterol should also be monitored be- with hydrochlorothiazide as Aldactazide, • Nausea, vomiting fore and during treatment. Some diuretics Dyazide, Maxzide and Moduretic. • Irregular heart rhythms actually raise cholesterol levels. Lozol They have many of the same side effects does not have this complication. and precautions as the diuretics discussed *Symptoms are not a reli- Cautions: Anyone allergic to thiazide above. They may still deplete magnesium, able indicator of potassium diuretics, sulfa drugs or oral diabetes and this crucial mineral should be mea- imbalance. Blood tests are sured periodically. essential. drugs should not be taking these medi- cines. Rash or itching should be reported One of the biggest problems with promptly, as it may be a sign of allergy. If these potassium-preserving pills is the you have kidney or liver disease, lupus potential interaction with the ACE in- or asthma, inform the doctor of your hibitor category of blood pressure medi- condition, as certain diuretics may make cines (Aceon, Accupril, Altace, Capoten, No one should ever stop Lotensin, Mavik, Monopril, Prinivil, or start taking medicines your situation worse. In some cases these drugs may increase blood sugar or ag- Univasc, Vasotec and Zestril). Because without careful medical the ACE inhibitors also preserve potas- supervision. Remember, gravate gout. Side Effects: Adverse events are sium, levels of this electrolyte could rise your pharmacist can pro- dangerously. If a physician prescribes a vide valuable information uncommon. Increased urination is an- ticipated, so taking such medicine early potassium-sparing diuretic and an ACE about side effects and in- inhibitor simultaneously, medical super- teractions! Please report in the day may reduce the number of times you have to get up at night to go vision must be extremely meticulous with any symptoms to your frequent blood tests. Symptoms of too physician promptly. to the bathroom. Muscle cramps, upset stomach, loss of appetite, diarrhea, diz- much potassium include breathing dif- ziness, sexual difficulties, increased ficulty, weakness, confusion, slow heart rate and heart rhythm changes. 6 ACE Inhibitors The ACE Cough Many of our readers have complained to us These blood pressure drugs block an en- about the annoying cough they experience ACE Inhibitors zyme called angiotensin converting enzyme. while taking ACEs. One wrote: “My husband Aceon perindopril Some are also useful in controlling conges- and I were on Altace. The coughing was un- Accupril quinapril tive heart failure. Vasotec and Capoten may bearable. Our family doctor put us both on Altace ramipril help preserve kidney function in diabetics Diovan and the coughing stopped, but NOT as well, and ACE inhibitors may be benefi- right away. It diminished gradually and all Capoten captopril cial for secondary stroke prevention when too slowly for us!” Another reader reported: Lotensin benazepril paired with diuretics. It’s hard to say which “I took lisinopril and developed a cough that Mavik trandolapril are “best” without head-to-head trials, but would start with a terrible tickle in my throat. Monopril fosinopril cardiologists we trust seem to prefer longer- Neither cough drops nor syrup had any effect Prinivil lisinopril acting Aceon, Altace, and Mavik. on the problem. I had been taking a generic Univasc moexipril Cautions: Because ACE inhibitors are form of the drug for about the same interval Vasotec enalapril generally well tolerated, they are widely I’d been coughing, and the doctor suggested Zestril lisinopril used. But some people may develop life- I go back to the original. But the pharmacist threatening allergies to these drugs. Swell- cautioned that both versions contained the ing of the face, tongue, lips and airways can same ingredients, so I might not notice any make breathing difficult. At the first sign difference. Since I am a singer, I could not of such a reaction, emergency treatment is take a chance and stopped taking the drug essential. Pregnant women must avoid ACE altogether. I will let my doctor know, but in ACE-Aspirin inhibitors; such drugs can be toxic to the the meantime I continue to exercise, watch nd rd Interactions fetus during the 2 or 3 trimester. Blood my diet, and take my BP regularly. So far disorders and kidney problems are rare but no problems.” Many physicians are unaware serious complications of ACE inhibitors. For those who have a hard time control- that aspirin may reduce the People with kidney or liver disease require ling their blood pressure with diet, exercise effectiveness of ACE inhibitors. dose adjustments and monitoring. and non-drug approaches alone, though, This may occur at aspirin doses ACE inhibitors may occasionally raise there are other options. of 325 mg or greater, whereas potassium to dangerous levels. For this rea- low doses (100 mg) do not son it is important to avoid extra potassium, seem to be a problem. See: either as a supplement or salt substitute. Guazzi, M. et al. Clin. Pharmacol. Angiotensin Recepter Ther. 1998;63:79-83. Side effects: Most people do well on ACE Hall, D. et al. J. Am. Coll. inhibitors, but if blood pressure drops too Blockers Cardiol.1992;20:1549-1555. low, some individuals may become dizzy or Angiotensin receptor blockers, or ARBs, faint. This is more likely after the first few work in a way similar to ACE inhibitors. doses, so extra caution is important early in They’re less likely to cause the persistant, treatment. A dry, hacking cough can be an nagging cough that can be associated unpleasant side effect of ACE inhibitors. If with ACEs, though, so they can be a such a cough persists, please tell your doc- good alternative for people who can’t tor. Other possible adverse effects include tolerate ACEs. rash and itching, stomach upset, headache, Angiotensin Receptor Are ARBs as good as ACEs at control- weakness, irregular heart beats, fluid reten- ling high blood pressure? The answer Blockers tion, sexual difficulties, elevated enzymes seems to be yes. Some cardiologists are Atacand candesartan related to kidney function, and sensitivity now prescribing ACEs and ARBs in com- Avapro irbesartan to sunburn. Some ACE inhibitors may cause bination for maximum blood-pressure- Benicar olmesartan loss of taste sensation. lowering benefits. One issue that you Interactions: Diuretics that spare potas- Cozaar losartan may want to discuss with your physician, sium such as Aldactazide, Dyazide, Maxz- Diovan valsartan however, is that there is still some ques- ide and Moduretic (see page 6) may cause Hyzaar losartan + tion about whether or not ARBs are as dangerous potassium overload in combina- effective at preventing heart attacks as HCTZ tion with ACE inhibitors. Other drugs that ACEs. As with ACE inhibtors, pregnant Micardis telmisartan may interact include aspirin and the arthritis women must avoid these medications. Teveten eprosartan medicines Clinoril, Dolobid and Indocin, Side effects: Adverse reactions are the gout medicine allopurinol, lithium, rare but may include stomach upset, cyclosporine, oral diabetes medicines, and muscle cramps, and dizziness. rifampin. Check with your pharmacist Ineractions: Cozaar interacts with and physician regarding any other drug in cimetidine (Tagamet) and barbiturates. combination with ACE inhibitors. 7 Calcium Blockers Calcium Blockers Beta Blockers Adalat nifedipine Calcium channel blockers became popular Beta blockers are some of the most widely Calan verapamil in the 1980s because they appeared to have prescribed blood pressure drugs; more Cardene nicardipine fewer side effects than previous drugs. Not than 115 million prescriptions are dis- Cardizem diltiazem only did they control angina and blood pensed for them annually, with atenolol pressure, they offered relief for a variety of and metoprolol at the helm. They’re Covera-HS verapamil other problems including certain arrhyth- also used to control angina, normalize Dilacor XR diltiazem mias, migraines, strokes, and Raynaud’s irregular heart rhythms, lower the risk of DynaCirc isradipine syndrome. repeat heart attacks, prevent migraines Isoptin verapamil There are now data to suggest, however, and diminish performance . Norvasc amlodipine that their safety may be in question. Instead They vary widely in their side effect Plendil felodipine of a clear indication that calcium antagonists and interaction profiles, but we now have Procardia nifedipine improve and prolong life, there is concern fairly grave concerns about some of their Sular nisoldipine that some of these medications may actually hazards. We would not recommend these predispose certain people to heart attacks drugs as the first or even second line of Tiazac diltiazem and increase the risk of heart failure. defense for controlling high blood pres- Vascor bepridil Clearly there are specific situations in sure. They’re simply not as effective as Verelan verapamil which drugs like Norvasc, Calan, Card- they should be, particularly atenolol. izem, Covera-HS, Isoptin and Verelan There are many beta blockers, so what may be necessary. And of course no one follows is general information. For more should ever stop any medication without details on a specific drug, please check Beta Blockers medical supervision. But be sure to discuss with your physician and pharmacist. Blocadren timolol all potential risks and side effects of your Cautions: People who have asthma medications with your physician. Cartrol carteolol and other serious breathing problems Cautions: Older people may be vulner- can get into terrible trouble with many Corgard nadolol able to dizziness if they stand suddenly. beta blockers, as these drugs can lead Inderal propranolol Severe heart conditions or kidney or liver to constricted airways. Diabetes and Kerlone betaxolol disease may create special problems for thyroid disorders may also be harder to Levatol penbutolol people on these medicines. treat. Never stop a beta blocker suddenly, Lopressor metoprolol Side Effects: Nifedipine can produce since this could trigger angina, irregular Sectral acebutolol flushing, dizziness, headache, nausea and heart rhythms or even a heart attack. Tenormin atenolol fluid retention (swollen ankles or hands). Side Effects: Some effects associated Other adverse effects may include irregular propranolol Toprol XL metoprolol with drugs like include slow heart beats, breathing difficulties, trouble heart rate, cold hands and feet, fatigue, Visken pindolol sleeping or sexual problems. Verapamil stomach upset, insomnia, nightmares, Zebeta bisoprolol can cause constipation, hair loss, dizziness, shortness of breath, rash, hair loss, swollen hands or feet, sexual difficulties, blurred vision, dizziness, joint pain and Beta-Blocker Blues headache or rash. Diltiazem is often well sexual difficulties. Some people experi- tolerated, but some people experience fluid ence the “beta blocker blues”: depression, Beware of the beta-blocker retention, dizziness, headache or flushing. nightmares, confusion, memory prob- blues. When one of our Other reactions include nausea, consti- lems, and lethargy. Cholesterol elevation readers was prescribed pation, sensitivity to sunburn and rash. beta blockers, he reported: may also occur with certain beta blockers, “I went through a living hell Amlodipine may produce rash, dizziness, so blood tests are recommended. because I became se- headache, weakness, upset stomach, swol- Interactions: Other blood pressure verely depressed. When I len gums, fatigue and fluid retention. pills may be prescribed in combina- complained [to my doctor] Interactions: People with heart rhythm tion with beta blockers. If clonidine of my depressed feelings problems may be prescribed quinidine, (Catapres) is stopped suddenly in such and asked if the medica- which may be dangerous in combination a situation, blood pressure may rise to tion might be responsible, with nifedipine or verapamil. When a beta life-threatening levels. NSAIDs may he brushed my concerns blocker is combined with a calcium antago- reduce beta-blockers’ effectiveness. aside and prescribed an nist, cardiac function should be monitored antidepressant. It made Other medications that may interact me anxious and gave me carefully. Certain calcium blockers may also with beta blockers include ampicillin, insomnia, so he added a interact with antidepressants, barbiturates, anti-psychotics, barbiturates, cimeti- tranquilizer.” carbamazepine (Tegretol), cimetidine dine, ergotamine, oral contraceptives, (Tagamet), cyclosporine (Sandimmune), rifampin, theophylline and some drugs digoxin (Lanoxin), grapefruit juice and for irregular heart rhythms (amiodarone, theophylline. flecainide, propafenone, quinidine). 8