Blood Pressure Medications Explained

Cardiologist Dr. Michael Koren sits down with Alisa, a person concerned about her blood pressure and the medications she is on. Alisa explains her history of pregnancy-related hypertension and the challenges she has faced with controlling her blood pressure before Dr. Koren reviews her medication list. The heart doctor explains what each of the medications does in the context of blood pressure, electrolytes, heart health, and other organs. Then he gives some explanation of why certain medications may be chosen over others, different delivery methods for medications, and the potential of new treatments emerging in the clinical research setting. Alisa also talks about difficulty paying for medications and procedures. Dr. Koren concludes by emphasizeing that treatment must be individualized to each patient.

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Transcript

Welcome And Consent To Share

Announcer 0:00

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren 0:11

Hello, I'm Dr. Michael Koren, the executive editor for MedEvidence! Getting to do what I actually like to do most, which is talk to a person who's not my patient, but who approached me recently thinking that I might be helpful to her because of the fact that I'm a research cardiologist and I look at things from maybe a little bit of a different perspective than an average physician in the community. So I want to ever introduce everybody to Alicia. Thank you for being part of MedEvidence. And I'm just going to say that before I do anything, I want your permission to discuss this because this is public now. A lot of people might be viewing this. I want to make sure that it violating any of your rights in terms of having this discussion openly. So are you very comfortable having a conversation about your health publicly?

Alisa 0:59

Yes, I'm very comfortable.

Dr. Michael Koren 1:00

Okay.

Alisa 1:01

I give my permission.

Dr. Michael Koren 1:02

Okay. So I'm I'm just going to mention your name as Alisa, and we're not going to go further than that. And whatever detail you want to share is fine. If there's a detail you don't want to share, that's fine too.

Alisa 1:12

Okay.

Dr. Michael Koren 1:12

But my understanding is that we're going to kind of go through your medication list because you're very concerned about your treatment for high blood pressure.

Alisa 1:19

Yes, correct.

Dr. Michael Koren 1:20

And we uh we're working on a project together professionally. I won't go into that. But during our work together, I discovered that this has been a source of deep concern for you, anxiety, in fact.

Alisa 1:32

Yes.

Dr. Michael Koren 1:33

And that you're on a lot of medicines for blood pressure, and we want to analyze how these medicines might be in your best interest over long term. And again, my perspective about how to use these medications from the viewpoint of a research cardiologist.

Alisa 1:47

Okay.

Dr. Michael Koren 1:47

So we're good to go on that?

Alisa 1:48

Yes, let's go.

Post Pregnancy Hypertension And ER Scare

Dr. Michael Koren 1:49

Okay. So we'll start by having you tell our audience just a little bit about you, uh, how old you are. You can add things about where you live if you like, and when you're first diagnosed with high blood pressure.

Alisa 2:00

Okay. I'm Alisa, and I live on the outside of Atlanta in a town called Hampton, Georgia. And when I was 38, I had a late pregnancy, you know. And so after the pregnancy, a lot of complications arose. And one of them being the hypertension and diabetes. And so after that, it just seemed like my health just could just could not recuperate from that. And so I ended up seeking, you know, medical advice in different places and stuff. And so my primary doctor, you know, I was telling him I was concerned about my blood pressure because it kept going higher and higher. So he was like, okay, let me give you this medication. Then we'll try another medication. I'll come back for the next visit. That didn't work. He said, it seems like it's not, you know, taking, you're not taking well with this. So we changed the medication probably about five times.

Dr. Michael Koren 2:56

Okay.

Alisa 2:57

And recently, for over a year, my blood pressure was out of control where I ended up in the ER where urgent care. And urgent care immediately had me to go to the emergency room where they did a million tests on me. And so

Dr. Michael Koren 3:13

How high was the blood pressure when you went to the emergency room?

Alisa 3:16

It was 200 and six over 200 and something.

Dr. Michael Koren 3:22

So usually the second number is going to be below that. So 206 over 100 something?

Alisa 3:27

No, it was 200.

Dr. Michael Koren 3:28

Okay. Was it 260 over 200?

Alisa 3:31

Yes. Uh-huh. It was like 260 over.

Dr. Michael Koren 3:35

Yeah, that may be slightly inaccurate because usually there's a pretty big difference between the top number, the systolic blood pressure, and the di astolic, but it was it was definitely over 200.

Alisa 3:43

Both of them were over 200. I it's been a minute, so I can't know.

Dr. Michael Koren 3:46

No worries.

Alisa 3:47

I don't know the exact numbers.

Dr. Michael Koren 3:48

And were you? Were you having any symptoms? Were you feeling bad? Or did they just discover?

Alisa 3:53

I was just tired and I just I woke up, I just couldn't move.

Dr. Michael Koren 3:57

Any visual problems or speech problems? What type of problems were they?

Alisa 4:02

I was having headaches and I everything was blurred, but I was thinking that was because of the diabetes. Because I had just gone to see my uh my ophthalmologist, and he was like, something is out of control.

Dr. Michael Koren 4:15

Okay.

Alisa 4:15

And so you saw a lot of pressure in my eyes and stuff.

Walking Through A Complex Med List

Dr. Michael Koren 4:18

So we're not gonna go into all details of your medical history, but I want to actually go through the [medication] list that you gave me.

Alisa 4:26

All right.

Dr. Michael Koren 4:27

And I'm gonna go it in order. Uh viewers and listeners uh will hear or see it, depending on how they're viewing this podcast.

Alisa 4:34

Okay.

Dr. Michael Koren 4:35

But it's in the order that you presented it to me.

Alisa 4:37

Uh-huh.

Dr. Michael Koren 4:37

Okay. And I just want to confirm that these are all accurate.

Alisa 4:41

Yes.

Dr. Michael Koren 4:41

So I have your list as clonidine 0.2 milligrams, and you take that as needed when your blood pressure is over a certain level. Maybe 190, 180.

Alisa 4:52

Yes.

Dr. Michael Koren 4:52

Okay. And then spironolactone with hydrochlorothiazide, 25 slash 25 daily.

Alisa 4:59

Yes.

Dr. Michael Koren 5:00

Nifedipine, extended release, 60 milligrams once a day.

Alisa 5:04

Yes.

Dr. Michael Koren 5:04

Okay. Hydralazine, 100 milligrams twice a day?

Alisa 5:08

Yes. Morning and at night.

Dr. Michael Koren 5:09

Okay. Metformin, which is for diabetes, estradiol, which is hormone replacement. Simvastatin, 80 milligrams. Do you take that at night or in the morning?

Alisa 5:19

At night.

Dr. Michael Koren 5:19

At night? Once a day at night?

Alisa 5:21

Yes, once a day at night.

Dr. Michael Koren 5:22

And uh you take Novolog, 100 units. How often do you take that?

Alisa 5:27

As needed.

Dr. Michael Koren 5:28

Okay. Okay. And you check your blood glucose every day or once in a while, or how often?

Alisa 5:34

I did have the patch, but uh now I'm just checking it uh every once in a while because since now I have it regulated pretty good.

Dr. Michael Koren 5:41

Got it. And then you take a multivitamin with iron.

Clonidine Fast Drops And Rebound

Alisa 5:44

Yes. Uh-huh.

Dr. Michael Koren 5:45

Okay. Sounds great. So just to go through this, so clonidine is being used on a PRN basis or as needed basis. And it's it's commonly used this way. It's an alpha blocker. And the reason doctors often prescribe it is that it works really fast. The problem with clonidine, from a research standpoint that I don't love, I'm not crazy about it, is that it's just a short-term fix. So it lowers your blood pressure, even 50, 60, 70, 80 points relatively quickly, maybe within a half hour, drops it down for about four hours and then it goes right back up.

Alisa 6:21

Exactly.

Dr. Michael Koren 6:21

And sometimes it goes up even higher than where you started. So it's really not a great long-term solution, of course. And the short term, it could drop your blood pressure too much, so that you go from being really, really high to so low that you get up out of a chair and you fall down and break your hip.

Alisa 6:37

Yeah.

Diuretics Calcium Blockers And Hydralazine

Dr. Michael Koren 6:38

So it's one of those things that doctors use it because they're worried that you're gonna have a stroke, but it can cause problems with actually low blood pressure because it's almost too effective in the short run. So just something uh consider. Second is spirono lactone hydrochlorothiazide. Those are two types of diuretics. One blocks a system called aldosterone, and the other one is called a thiazide diuretic. That's a really good choice. Diuretics should be a good centerpiece for the treatment of hypertension. And the neat thing about using spirno lactone with hydrochlorothiazide is that one lowers potassium and then one raises it. So you're getting that extra fluid out of the system, the extra salt out of the system, but it's balancing each other in terms of potassium. So that's a really good choice. I love that.

Alisa 7:26

Okay.

Statin Interaction Risks To Flag

Dr. Michael Koren 7:27

Nifedipine ER is an interesting drug. It's called a calcium channel blocker. And nifedipine was a short-acting calcium channel blocker that was originally marketed by Pfizer. And they put it together to create a slow release format because some of the problems of a short-acting drug were offset by making it longer acting. The problem with nifedipine is it actually reduces the muscle contraction of the heart. We call that a negative ionotrope. And it may not be the best drug to use for a lot of people, but it is effective. A lot of people think it's particularly effective in African-American patients, so that's why they're using it. But I have a couple of issues with that that we'll get to in a second. Hydralazine is a relatively short-acting vasodilator. The truth is that you're taking it twice a day, and probably you need to take it three or four times a day to give you full coverage. But it's again one of those drugs that works relatively quickly. Certain of the blood pressure drugs that we use work quickly, and there's others that don't work so quickly. Metformin is for diabetes, and then we'll touch more on that. Estradiol is for hormone replacement. Then you're on simvastatin for cholesterol, which is it's a it's a drug that was wonderful for a long, long time, but it's a shorter-acting cholesterol drug, and it doesn't particularly play well with nifedipine. There's an interaction between those two drugs. So I don't typically use nifedipine and simvastatin together. And if you've ever tried a torvastatin or rosuvastatin, rosuvastatin would probably be the best for you, in my opinion, because it's less likely to have a drug-drug interaction with a calcium channel blocker. So just some food for thought. And then uh you're taking your insulin. We talked about that in the multivitamin. Last but not least, I noticed that you're on Ozempic one milligram per day.

Alisa 9:18

Yes.

Dr. Michael Koren 9:19

How long have you been on that?

Alisa 9:21

I was on it for a year, but then I had to stop because I had the wrong plan, and it was costing me at that point, it was like a hundred and some out of pocket. But with the new insurance that started in January, it's like eighty to six dollars.

Dr. Michael Koren 9:34

So still a little pricey, but you can get into your budget.

Alisa 9:39

Yes.

Ozempic Benefits Cost And Side Effects

Dr. Michael Koren 9:39

And Ozempic, the the generic name for that is semaglutide, and that's called a GLP-1 agonist. And this is a very powerful class to both help with diabetes, with weight loss, and also lowers your blood pressure. I don't know if you knew that.

Alisa 9:56

Yes, they they're treating me for my A1C with the uh Ozempic. That's the main reason, but I also I needed to lose weight, but that was the primary reason when I went to an endocrinologist. They, you know, recommended me on the use of Ozempic.

Dr. Michael Koren 10:13

Yeah, so as a research cardiologist, I was first introduced to Ozempic because the FDA mandated cardiovascular safety studies for it.

Alisa 10:22

Oh, okay.

Dr. Michael Koren 10:23

So it was a diabetes drug, and not all diabetes drugs are completely safe from a cardiovascular standpoint. Some have been associated, for example, with worsening congestive heart failure. So the FDA advised the company to do safety studies with Ozempic. And lo and behold, not only was it good at lowering your diabetes, but it also lowered your cholesterol and your blood pressure. And now we know that it actually reduces cardiovascular risk. You have fewer heart attacks and strokes when you take Ozempic. And it's not just for Ozempic, it's Mounjaro in that class and others now have been proven that this class of GLP-1 agents are highly effective agents for not only dealing with diabetes short term, not only dealing with weight loss short term, but reducing cardiovascular risk. So I'm very pleased to see that you're on that.

Alisa 11:09

Yes.

Dr. Michael Koren 11:09

So, Alisa, you're on a lot of drugs. How do you keep up with all this? It must be hard.

Alisa 11:14

Well, I have I invested in these little containers that are Monday through Sunday. And so I every, you know, every month I take time out every so often because it's like four for seven days. So it takes me through the month. But I at night I just go through each one of my peer bottles. Some are taken in the morning. So I have a second set of containers for the morning. And then I have one for night. And I just have them so each night I just pull them out.

Dr. Michael Koren 11:45

Okay.

Alisa 11:45

Because they're prepared already.

Dr. Michael Koren 11:46

So you think you're doing a pretty good job of keeping on track with this complicated regimen?

Alisa 11:50

Yes. I want my health to improve.

Dr. Michael Koren 11:52

I love that.

Alisa 11:53

I do. I'm so invested in, you know, trying to improve. I have a daughter that's 20 with 21 this year, and I want to be around.

Dr. Michael Koren 12:01

Absolutely. Well, I love that.

Alisa 12:02

Yes.

Dr. Michael Koren 12:03

That's terrific. How about the cost of all these drugs?

Alisa 12:05

They're very expensive. And I just have to budget, you know, because they kind of overlap when they're because they're on an auto-refill.

Dr. Michael Koren 12:16

Sure. And so now some of them are generics that hopefully are not terribly expensive, but that is always a consideration.

Alisa 12:22

I've had to kind of hold off on one. And Ozempic was one of those. But for the most, the primary ones with the diabetes and hypertension are my primary concern.

Dr. Michael Koren 12:33

Right. The the good news for you is that there are a lot of available generic drugs for blood pressure, so they shouldn't be too pricey. But you should always ask questions to make sure you're getting the best possible deal and ask your physician about it. If there's one that is particularly higher than the other in terms of the blood pressure medicines and their cost, mention to the doc and they may be able to help you with that.

Alisa 12:55

Well, he did. He gave me this card of uh some RX.

Dr. Michael Koren 12:59

Okay.

Alisa 12:59

And it searches around for the best prices. So I have been able to go to different places to get a better price for the medication. That was very helpful from him.

Dr. Michael Koren 13:09

That's terrific. So the other question I want to ask you is about the GLP-1 drug. You're on one milligram uh per week right now.

Alisa 13:18

Yes.

Dr. Michael Koren 13:18

Have you tried a higher dose?

Alisa 13:21

Yes, but by me having intestinal problems from the past, they didn't take well. I was very sick and it just made my stomach hurt all the time and I felt bad. So that's brought me back down.

Dr. Michael Koren 13:35

Did did that medication help you lose weight?

Alisa 13:37

I have not lost any weight.

Dr. Michael Koren 13:40

Interesting.

Alisa 13:41

I have not lost any weight. I don't know why, because I don't eat as much, because my stomach only allows me to eat, you know, a little bit, and then I get full.

Dr. Michael Koren 13:50

Right.

Alisa 13:51

But then I feel like I'm overstuffed for some reason. And that's probably the intestinal issues I've had in the past.

Dr. Michael Koren 13:58

Right. So GLP-1 agonists are very effective drugs for helping people lose weight, but there are some people that don't respond as well as others. And there's a lot of research going on to try to make this class of drug even better and more impactful than it already is. So it's another place where research may have some benefits to you.

Alisa 14:18

Well, he wanted to try me on another one, but insurance, again, they only cover certain drugs like that.

Dr. Michael Koren 14:26

So well, again, the beauty of the research programs is they're typically funded by external parties and there should be no out-of-pocket cost to you. But you always have to look into the details and do that with one of the study physicians or your doctor to make sure that it's a good fit for you. But I will say this is an area of very active research, and there may be a lot of opportunities that will help you lose weight. And you know what? When you lose weight, your blood pressure comes down.

Alisa 14:50

I know I've been told. But I'm interested in uh any kind of study they may have in in my area. I did reach out to one for diabetes, but I haven't I didn't think about it until you just mentioned about, you know, the blood pressure.

Longer Acting Options Like ARBs

Dr. Michael Koren 15:05

So when I look at this, and again, I'm not your physician, and these are just to help you generate questions for physicians, for your physician, is whether or not you should be considered for a longer-acting type of medication. So what's not on your list is a class of drugs that blocks a hormone system called the renin angiotensin system. And there's many of these drugs, but the most commonly used drug in the class is called angiotensin receptor blockers. Losartan, valsartan are typical agents in this. Cozaar is the trade name for Losartan, for example. Have you ever been on an angiotensin receptor blocker, to your knowledge?

Alisa 15:46

He once put me on Losartan. Then all of a sudden, when I went back for the next visit, no, I got a call to quit taking it. And that's when he put me on the other, he had me on what was the other ? I can't even think of it.

Dr. Michael Koren 16:00

Well, I don't know all the details, but Losartan is not a drug that works fast, but it blocks this hormone system that drives blood pressure up over time. And also protects your organs against the effects of high blood pressure. Now, there is, there are data to show that some of these drugs don't work quite as well in the short run for African-American patients. And that might have been one of the considerations. But somebody like you that's already on five medicines here for blood pressure, I think should be on a drug that blocks that system, angiotensin receptor blocker. Okay. And Losartan may not be the most effective in that class, but it's it was the first one and it's and it's very, very commonly used. But there's a whole class of those types of drugs that tend to work better in African Americans when you combine them with a diuretic. So that'd be a question. I would go back to the doctor and say, ARB, angiotensin receptor blocker. Is that something I should be on as a longer-acting drug? There's other classes that are longer acting drugs that you're not on that I'm not necessarily recommending, but yeah, beta blockers, for example. Some are combination alpha-beta blockers like carvedilol that work a little bit better in African-American patients compared to other ethnicities and races. And these are questions I would ask, but I would say I would prioritize the concept of that ARB angiotensin receptor blocker. I'd also ask the question about using the simvistatin with nifedipine. I'm not a huge fan of nifedipine. There are other calcium channel blockers that I prefer over nifedipine for a number of reasons, but the interaction between the statin that was chosen and the blood pressure medicine is chosen is not ideal in my view. And I would ask that question.

Alisa 17:40

He did have me on atorvastatin one time.

Dr. Michael Koren 17:42

A torvostatin. Yeah. Okay.

Alisa 17:45

And they changed it.

Dr. Michael Koren 17:46

Yeah. That would I would be curious why they changed that. I would think that's a better product for you, but actually probably the best is rosuvastatin, because it's less likely to have that drug-drug interaction with a calcium channel blocker. And then I have questions for you. Now you you mentioned before we got online that you have not had a heart attack or stroke or major complications, haven't had kidney failure or major eye issues.

Echo Testing Costs And Secondary Causes

Alisa 18:13

I had eye issues, but like I said, that was pertaining to diabetes. But I the the primary care had a uh had me on this uh call, and the lady said, you need to go to a cardiologist. She says, your blood pressure is running too high over too long of a period of time. So that's when I reached out to a cardiologist. Well, for the first visit, first-time patient visit, and for the EKG, the visit was over $500.

Dr. Michael Koren 18:44

Okay.

Alisa 18:44

Which was, you know, kind of shook me a little bit. So I was like, I can't afford this right here for the And your sure

Dr. Michael Koren 18:52

insurance didn't cover that?

Alisa 18:53

Well, they they reached out to the insurance and they said this was what I was owed out of pocket. And I was like, I wasn't expecting it. So I canceled the uh echo, which they had scheduled.

Dr. Michael Koren 19:05

Yeah, that would be a really good idea because the echo will tell us the size and shape of your heart and how how it's reacting to your level of blood pressure.

Alisa 19:14

Okay.

Dr. Michael Koren 19:14

Reacting to it adversely, or is it kind of compensated? It's actually a very, very important test in your situation. So you may want to talk to the practice and say, uh, what why did I get this amount of a bill? It may be a deductible issue or a copay issue. You might have to work that out and figure that out. But I I would say that you want to talk to your doctor about understanding how your organs are responding to the high blood pressure and also addressing whether or not you have secondary hypertension because you presented with hypertension at a relatively early age during a pregnancy. And you want to make sure that there are no kidney hormones that are driving this, for example. You want to make sure that the kidney arteries are not driving the problem. You want to make sure you're not overproducing certain steroid hormones that can be causing the problem. And there's other things that we look at. But all these things are valuable based on working with your physician and digging into some of these issues. And given how high your blood pressure is, despite the fact that you're on multiple drugs, I think that would be something that I would really want to dig into a little bit with a physician. So hopefully that gives you some information. You're armed with a with the power of knowledge.

Alisa 20:28

Yes.

Dr. Michael Koren 20:28

Now to ask some really good questions.

Alisa 20:30

Yes.

Dr. Michael Koren 20:31

Do you have any questions for me as as we wrap this up, this little discussion?

Alisa 20:36

Yes, I know the pharmacy reached out to me about the the Losartan. And they I think that's why the doctor changed it too. What which drug on that list would conflict with that Losartan?

Losartan Potassium Concerns Explained

Dr. Michael Koren 20:51

There's nothing that would conflict with Losartan unless your potassium level was high. And the spironolactone can raise the potassium. And in some patients, Losartan raises potassium.

Alisa 21:03

Okay. Because they were saying those two drugs were not supposed to be used together.

Dr. Michael Koren 21:10

Yeah, I'm not sure what what their concern was, but there might have been something else that is not no longer on the list that may may be an issue.

Alisa 21:17

Okay.

Dr. Michael Koren 21:18

But uh in general, that class of drugs is a good class for you to be on. And again, you always have to look at the labs, you have to look at the the kidney function, you have to look at the electrolytes, particularly the potassium, and those are important elements of good care. But all that should be coordinated through your physician.

Alisa 21:35

And one last question. Okay, if I do have them, if they were to re-evaluate this list and the drug that you mentioned that should have angio somthing in it.

Dr. Michael Koren 21:46

Angiotensin receptor blocker, yeah.

Alisa 21:47

Would it eliminate the amount of blood pressure pills I have to take daily?

Could Fewer Pills Work Long Term

Dr. Michael Koren 21:53

Possibly, but I I don't know that for sure until until you actually look at these things and try. So there may be other opportunities. Here. So for example, clonidine is an alpha blocker. And if that's a good drug for you, then instead of just taking it 0.2 milligrams every once in a while, you consider wearing a patch, but gives you a steady dose over time.

Alisa 22:14

Okay.

Dr. Michael Koren 22:14

Or using a longer duration alpha blocker that you take once a day. So that might be a good choice for you, but you'd have to work with your doctor on that.

Alisa 22:24

I wasn't even aware they had a patch.

Dr. Michael Koren 22:25

Absolutely.

Alisa 22:26

Okay.

Dr. Michael Koren 22:27

It's a good strategy for a lot of people, yeah.

Alisa 22:29

Okay.

Dr. Michael Koren 22:30

And of course, there's all kinds of research going on with treating high blood pressure. So we're more than happy at some point to connect you maybe with a research site in your community in Atlanta. Or if you're going to visit here in North Florida on a regular basis, we're more than happy to look at that for you as well.

Alisa 22:46

Okay. I look forward to it.

Next Steps And MedEvidence Resources

Dr. Michael Koren 22:48

So, Alisa, thank you so much for being part of Med Evidence! Thank you for sharing these personal details with our audience. And hopefully you're now armed with some really good questions so that you can improve your care for the hypertension and keep you safe from a cardiovascular viewpoint.

Alisa 23:04

And I appreciate you taking the time to give me a review of everything and the questions and stuff that I can go back to.

Dr. Michael Koren 23:13

It's my absolute pleasure.

Alisa 23:15

Thank you.

Announcer 23:16

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