Prevalence of Medications That May Raise Blood Pressure Among Adults With Hypertension in the United States

Abstract

This cross-sectional study characterizes the prevalent use of medications that may raise BP and examine their associations with BP control and antihypertensive use.

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.

Methods

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).

Results

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%).

Table 1. Prevalence of Use of Medications That May Raise Blood Pressure (BP) Among US Adults, 2009-2018.

	Survey participants, % (95% CI)
	US adult population	Adults with
		Hypertensiona	Uncontrolled hypertensionb
Unweighted No.	27 599	14 629	10 696
Weighted No.	225 284 279	111 056 498	79 921 633
Use of medications that may raise BP
Any	14.8 (13.9-15.8)	18.5 (17.5-19.5)	17.4 (16.3-18.5)
1	12.3 (11.7-12.9)	14.9 (14.1-15.8)	14.1 (13.1-15.1)
≥2	2.5 (2.2-2.9)	3.6 (3.1-4.1)	3.3 (2.7-3.8)
Use of classes of medications that may raise BP
Antidepressants	6.7 (6.2-7.3)	8.7 (8.0-9.5)	7.9 (7.0-8.8)
NSAIDs	4.9 (4.4-5.3)	6.5 (5.8-7.2)	6.2 (5.4-6.9)
Steroids	1.4 (1.2-1.6)	1.9 (1.6-2.1)	1.7 (1.4-2.0)
Estrogens	1.4 (1.2-1.6)	1.7 (1.4-2.0)	1.6 (1.3-1.9)
Stimulants	1.1 (0.9-1.4)	0.9 (0.6-1.1)	1.0 (0.7-1.4)
Testosterones	0.4 (0.2-0.5)	0.4 (0.2-0.6)	0.4 (0.2-0.6)
Antiobesity agents	0.2 (0.1-0.3)	0.2 (0.1-0.3)	0.1 (0.1-0.3)
Decongestants	0.2 (0.1-0.4)	0.4 (0.2-0.6)	0.4 (0.1-0.7)
Antipsychotics	0.1 (0.1-0.2)	0.2 (0.1-0.3)	0.2 (0.1-0.4)
Immunosuppressants	0.1 (0.0-0.1)	0.2 (0.1-0.3)	0.2 (0.1-0.3)
α Agonists	<0.01	0.0 (0.0-0.0)	0.0 (0.0-0.0)
Antirheumatics	<0.01	0.1 (0.0-0.1)	0.1 (0.0-0.1)
Use of antihypertensives
1	13.2 (12.5-13.9)	23.3 (22.2-24.4)	19.8 (18.8-20.9)
2	8.9 (8.3-9.4)	17.0 (16.0-18.0)	13.0 (12.1-14.0)
>3	4.9 (4.5-5.3)	9.8 (9.1-10.6)	7.9 (7.2-8.6)

Abbreviation: NSAIDs, nonsteroidal anti-inflammatory drugs.

^a Hypertension was defined as an average systolic BP reading of 130 mm Hg or higher, average diastolic BP reading 80 mm Hg or higher, or answering “yes” to a hypertension questionnaire.

^b Uncontrolled hypertension was defined as an average systolic BP reading of 130 mm Hg or higher or an average diastolic BP reading of 80 mm Hg or higher.

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).

Table 2. Association Between Use of Medications That May Raise Blood Pressure (BP) and Hypertension Control and Antihypertensive Use Among US Adults, 2009-2018.

No. of medications that may cause elevated BP	Odds ratio of uncontrolled hypertension (95% CI)a		Incidence rate ratio of antihypertensive use (95% CI)b
	Adults not taking antihypertensives (n = 19 149)	Adults taking antihypertensives (n = 8450)	Adults with controlled hypertensionc (n = 3933)	Adults with uncontrolled hypertensiond (n = 10 696)
0	1 [Reference]	1 [Reference]	1 [Reference]	1 [Reference]
Any	1.24 (1.08-1.43)	1.04 (0.90-1.20)	1.38 (1.22-1.54)	1.18 (1.09-1.29)
1	1.19 (1.02-1.40)	1.02 (0.86-1.20)	1.27 (1.11-1.44)	1.13 (1.03-1.25)
≥2	1.49 (1.06-2.10)	1.10 (0.82-1.47)	1.91 (1.49-2.45)	1.41 (1.21-1.64)

^a Odds ratios of uncontrolled hypertension were estimated from multivariate logistic regression models examining nonpregnant US adults and stratified by current use of antihypertensives. Model covariates included age, sex, race and ethnicity, having a usual place for health care, education level, household income, type of health insurance, and health care use in the past year.

^b Incident rate ratios of antihypertensive use were estimated from negative binomial regression models examining nonpregnant US adults with hypertension and stratified by hypertension control. Model covariates included mean systolic and diastolic blood pressure readings, age, sex, race and ethnicity, having a usual place for health care, education level, household income, type of health insurance, and health care use in the past year. Incidence rate ratios represent the estimated rate ratio of antihypertensive medications used for a 1-unit increase in the number of medications that may cause elevated BP, holding covariates constant. Thus, an increase in the use of medications that may cause elevated BP from 0 to 1 medication is expected to increase the number of antihypertensives used by a factor of 1.27 among adults with controlled hypertension and 1.13 among adults with uncontrolled hypertension.

^c Hypertension was defined as an average systolic BP reading of 130 mm Hg or higher, average diastolic BP reading of 80 mm Hg or higher, or answering “yes” to a hypertension questionnaire.

^d Uncontrolled hypertension was defined as an average systolic BP reading of 130 mm Hg or higher or an average diastolic BP reading of 80 mm Hg or higher.

Discussion

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.

Supplement.

eMethods.