Better Risk Assessment for Individual Substances

The colleagues Weber and Anlauf list substances with blood pressure-increasing effects to be considered in differential diagnosis (Box, p. 427).

However, for psychiatric medications it is not correct to link entire drug classes, such as antipsychotics, monoamine oxidase (MAO) inhibitors and tricyclic antidepressants, with arterial hypertension in the way presented in the article.

In contrast to the statements in the article, antipsychotics (or neuroleptics) are rather associated with orthostatic dysregulation and hypotension (e.g. quetiapine, risperidone, clozapine) than with hypertension, especially when patients are newly started on the medication; here, alpha1-antagonistic effects play a major role. Likewise, MAO inhibitors have mostly blood pressure-lowering effects. Only if dietary restrictions (low-tyramine diet) are not followed, patients are at risk for hypertensive crisis, with the risk of blood pressure increases being much higher for tranylcypromine, an irreversible, unselective MAO inhibitor, than for moclobemide or rasagiline. The same applies to tricyclic antidepressants where patients on the medication rather develop arterial hypotension and only in exceptional cases hypertension (e.g. under desipramine).

Not listed are some psychiatric medications frequently associated with marked increases in blood pressure. These include antidepressants with noradrenergic effects, such as venlafaxine (1), duloxetine (2), bupropion (3), reboxetine (reimbursed by statutory health insurances until 2011), and (levo-)milnacipran, and also prescription stimulants, such as modafinil/ adranafil, atomoxetine, and (lis-)dexamfetamine.

Overall, we would prefer if the risk assessment for blood pressure-elevating effects was performed for individual compounds instead of drug classes.