Print Michael Aaronson, M.D.

A patient with high blood pressure presented to my office with a severe headache. She has a history of seasonal allergies. The patient is adherent to her medication regimen. In the office, her blood pressure was 210/120. Normally, her blood pressure on therapy is 125/78. What is happening and what should we do?

It turns out the patient was outside with her family watching fireworks. Her allergies to pollen acted up, and she took pseudoephedrine to help control her symptoms. A side effect of this medication is hypertension.

I see a referral population which can be very different from the general population that sees a primary care practitioner. That said, I have seen many high blood pressure patients on allergy medications that have had bad outcomes: stroke, heart attack, kidney problems, and malignant (life-threatening) hypertension.

Both perennial and seasonal allergies can be annoying for a person. Its usually easy to tell an untreated patient with allergies because they give you the “allergic salute” (people with allergic rhinitis often rubs their noses using the index finger).

Many over the counter therapies for allergic rhinitis can worsen a patient’s hypertension. For instance, phenylephrine, the active ingredient in Sudafed, can also increase a person’s blood pressure. In fact, most decongestants (drugs that shrink the swollen membranes in the nose) may cause hypertension.

The best therapy for allergies in a patient with high blood pressure is an intra-nasal steroid. Avoidance of the allergens, if possible, also helps.

A cost-effective, generic nasal steroid that is not absorbed by the body is called fluticasone propionate which is currently $60 dollars a month at drugstore.com. Other steroid inhalers are available, but these can get very pricey.

There are other medication options for those on an extremely tight budget. The Walmart $4 list includes loratadine, which you can obtain via a prescription from your doctor. The medicine is generic and is the same thing as over the counter Claritin. This medicine is extremely effective and is a great second-line or add on therapy to the intranasal corticosteroid.

For those of you with hypertension and allergies who wish to try an over the counter nasal inhaler option, cromolyn sodium is available. Cromolyn stabilizes inflammatory cells which are involved in the allergy process. This medicine works. It is cost effective (around 12 dollars per inhaler), but the big downside here is that a person has to use it 4 times daily. I have found that many people are non-adherent to more than twice a day medication regimens. And if you don’t take the medication it won’t work. Therefore, Cromolyn is my third line therapy.

For those who do not like to take medication, nasal irrigation and saline sprays can be effective. Many of my patients find this form of therapy to be unappealing and give up on it quickly.

For the patient described here in the clinical vignette, I referred her back to her primary care physician for an allergy therapy assessment. I asked the patient to stop taking the pseudoephedrine and continue her current blood pressure medication therapy. Her blood pressure quickly returned to normal and with the help of her PCP (primary care physician), her allergies got better!



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