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Beta-blockers and tricyclic antidepressants are more commonly associated with orthostatic hypotension
Clinical Question
What medications are associated with orthostatic hypotension?
Bottom line
Beta-blockers — but not calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers — were associated with a 7-fold increase in the likelihood of causing OH as compared with placebo. Tricyclic antidepressants — but not selective serotonin receptor inhibitors — were associated with a similar increase. Second-generation antipsychotics were associated with an increased risk, as were SGLT-2 inhibitors used to treat type 2 diabetes. Of course, this meta-analysis could only include studies in which OH was tested and also reported, and the included studies largely excluded older patients who might be more prone (to OH) when not prone. 1a
Reference
Study design: Meta-analysis (other)
Funding: Foundation
Setting: Various (meta-analysis)
Synopsis
These authors searched 3 databases and identified 69 studies (N = 27,079 patients) that reported orthostatic hypotension (OH) as an outcome. One investigator, spot-checked by 2 other researchers, selected studies for inclusion and determined the risk of bias in the studies, which was deemed to be low for 40 of the studies. Three researchers independently abstracted the data. It's no surprise that, based on their pharmacology, beta-blockers and tricyclic antidepressants (which are also alpha-1 blockers) were associated with a 7-fold increase in the likelihood of OH. Alpha blockers used to treat urinary symptoms in men were associated with OH to a lesser degree, as were second-generation antipsychotics. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors were associated with a slightly increased risk of OH as compared with placebo (odds ratio 1.24; 95% CI 1.08 - 1.43). Surprisingly, there was no statistically significant difference in the likelihood of OH with calcium channel blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, or selective serotonin reuptake inhibitors (which were initially investigated to treat hypertension). The studies used in this meta-analysis were not specifically aimed at investigating OH, and many studies excluded older people who may be more likely to experience postural changes and, therefore, may be more likely to take these offenders.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
b-blockers and TCAs both contribute to syncope
both are on Beer's criteria, and so should be used with caution.
B-Blockers and OH
As OH is more common in the 'elderly', their exclusion is non-understandable
important
Important and relevant observation that will benefit many patients
oh big problem
other drugs
drugs causing OH
betablockers 7 x more likely and tricycyclics