April 25, 2014

Blood Pressure Pills for the Elderly: Why I'll Stop Taking Them

Of all my recent health issues, my biggest concern has been whether I should keep taking blood pressure medication. Ditching the pills would be a big deal, since I've taken various hypertension meds for at least 40 years.

A week ago, I summarized my bp history and concerns in a letter to a doctor regarded as a top specialist in this area. It was very detailed, and I've included it at the end of this post.

Here are the keys issues I raised:
  • The acceptable bp guideline for people 60 and older was recently raised to 150/90. Some authorities now argue that anyone over 80 -- without cardiac problems -- can stop taking the pills. Most of my readings are under 150/90, but I do have occasional spikes, many of which occurring in my "off" times, when the last levodopa pill is wearing off, and the next hasn't yet kicked in. But the biggest spikes are caused by nervousness, stress or anxiety. I recently described one incident that produced a reading of 240/120. Can I safely discontinue bp drugs?
  • I've been dealing with high blood pressure for years. But lately, I'm also having alarming drops in bp -- as low as 71/47. I've learned this issue is called orthostatic hypotension, and it's associated with Parkinson's. These big drops typically happen on warm days when I'm outside, standing and active. I get dizzy and come close to fainting or falling. How do I deal with this development?
  • The serotonin booster 5-HTP has helped me avoid Parkinson's common non-motor symptoms -- depression, insomnia and constipation. But taking more than the smallest dose (50mg) can produce alarming bp spikes. On the other hand, I've noticed recently that taking an extra 25mg of the supplement can ease other Parkinson's symptoms, like micrographia (small, cramped handwriting) and a shuffling gait. Can I find a dosage of 5-HTP that reduces PD's symptoms without sending my bp to dangerous levels?
Preliminary Discussion with My Blood Pressure Specialist
I spoke with the bp doctor on the phone yesterday. Here's some of what we discussed:

Pills or no pills?. He suggested I try half the normal dose of Avapro, a bp med I've used with some success. I mentioned that orthostatic hypotension was listed as a possible side effect of Avapro.

He said he "would not lose any sleep" if I decided to stop taking any bp meds, especially since the pills increase the risk of falling for seniors.

I had just seen a New York Times report on recent Yale studies that raised that same question. Here's how the issue was posed:
The Yale findings, which were published this month in JAMA Internal Medicine, mean that blood pressure management enters one of those increasingly common medical gray zones in which individuals and caregivers have to ask a lot of questions and balance the trade offs. 
Do you avoid a heart attack by using drugs associated with an almost equal risk of breaking a hip or injuring your brain? 
Dealing with Orthostatic Hypotension: My doctor suggested I might wear an abdominal binder. He's found them helpful, and they can raise blood pressure by 10 to 20 points.

Orthostatic hypotension seems to be an issue with me only when I'm active outdoors on warm days. At other times, my issue is elevated blood pressure. I asked if it would work if I just wore the binder on those occasions when I seem to be at risk. He thought that idea would be OK.

Blood Pressure and 5-HTP: He said he had no expertise on this issue. I agreed that it was more an issue to discuss with my neurologist.

So, What Do I Do Now?
I'll see him again in two weeks. In the meantime, I'll continue doing without the meds. But I'll continue monitoring my pressure at home and recording results in my journal. We'll review the numbers and discuss strategies when we meet.

I'll do an "Amazon one-click" on the abdominal binder later today. Maybe it will also create a "slimmer look."

I also raised the issue of our continuing to operate as we started: I supply a written report on my issues and questions, then we discuss them on the phone. I know I can provide more detailed, accurate information in writing than I ever could during an office visit. After all -- during typical doctor visits these days -- I talk while the doctor scrambles to enter what I'm saying into the computer. It's not a personal, friendly conversation.

The doctor agreed my suggestion might work better, but added that insurance companies and Medicare favor office visits.

I'll have more to say on taking notes and office visits next week.

# #  #  #  #  

Don't rush to your medicine cabinet and throw away your meds, or rush out and buy an abdominal binder. I always say that what works for me may not work for you. Sometimes, what I try doesn't even work for me. My decisions are based on my own unique set of circumstances.

For that rare individual who may want more information on how I'm dealing with blood pressure issues, here's an excerpt from the letter I sent my doctor:
Blood Pressure Meds Background
I signed on with a new internist earlier this year. After reviewing my history with blood pressure medications, she agreed I could try Avapro, which my son had recommended. It seemed to work. But I was also experiencing what I later determined was orthostatic hypotension.

On warm summer days I found that if I were doing even minimal exercise around noontime, I would experience sudden weak spells that at times had me close to fainting. I’ve been monitoring  my blood pressure several times a day for several years for reasons I’ll get to later. Thanks to this monitoring, I discovered the noontime sinking spells coincided with drops in blood pressure that brought the systolic number well below 100.

I later learned that orthostatic hypotension was associated with Parkinson’s. Then I found it listed as a possible side effect of Avapro.

Meanwhile, the January issue of the Mayo Clinic’s Health Letter had an article on two devices that studies found had the potential to help lower blood pressure – Resperate (that provides a guided breathing exercise) and Zona Plus, an isometric therapy device. I bought both and after using them for a few weeks my blood pressure readings were stabilizing at a relatively low level. So I tried cutting my Avapro pills in half. The readings remained below 150/90.

My internist agreed to a two-week trial of using the devices without taking any pills. The readings I got on my home monitor stayed below 150/90 for the most part.

I had an appointment to see my internist at the end of the two weeks. Before leaving home, I took my blood pressure and got a reading of 138/83. At her office the reading was 200/100!

She understandably recommended that we abandon the no-pills experiment. She gave me a prescription for Lisinopril 10mg and suggested we probably would increase it to 20mg. I tried the Lisinopril for a couple of weeks and began experiencing the cough that accompanied earlier hypertension meds. I’m now again trying no pills.

Here are the readings I got last Sunday which provide a fairly typical example of the readings I’ve been getting. (The “pill” notations indicate the times at which I take my levadopa pills. I’ve found that I frequently have bp surges if readings are taken during the levadopa “off” periods when an old pill is wearing off and a new pill hasn’t kicked in.)

7:30 am – 157/99
8 am – pill
10 am – 138/79
Noon – pill
12:30 pm –140/82
2 pm – 92/54!! (I’d been outside in the 80-plus heat. The only other low reading like this since last summer was a hot day in Uruguay in February. But I had other midday readings like this fairly often last summer. Most of these low reading coincided with dramatic sinking spells.)
4 pm – pill
4:30 – 146/85
5:30 pm – 126/71
8 pm – 150/86

Do I need to continue with blood pressure meds?

I write a blog “Aging and Parkinson’s and Me” -- http://parkinsonsand5htp.blogspot.com/. In the course of researching blood pressure issues for the blog, I’ve been intrigued by the debate over whether someone my age who has not had indications of cardiac problems needs to take hypertension medication.

I’d love to continue doing without the bp meds. My blood pressure journal shows that probably 80% of the readings during the past two no-pill weeks have been below 150/80 but it also documents some causes for concern.
  • As noted, I have spikes of readings above 150/90 associated with the “off” periods on the levadopa med. 
  • Stress, anxiety and nervousness can really escalate the readings. The escalation in my internist’s office is an example. An even more dramatic incident was when waiting an hour and a half for a cab to show up drove the bp reading to 241/120. I described this incident in a blog post -- http://bit.ly/RvScGH. I’ve had smaller spikes as a result of frustrations in dealing with the computer. In each of these cases, the readings soon drop back to the normal range within an hour or two.
  • My readings are very volatile. At a single sitting the readings can range from 175/100 to 135/85.
  • Overdosing on 5-HTP also can drive up the blood pressure. This warrants a closer look.

Blood pressure and 5-HTP
I’ve used 5-HTP periodically to deal with insomnia for years. But shortly after being diagnosed with Parkinson’s in 2009, I began taking it at bedtime consistently. I found even the smallest dose available – 50 mg – took care of three of the most prevalent non-motor symptoms of Parkinson’s – depression, insomnia and constipation. 

Following my life-long belief that anything worth doing is worth overdoing I at times experimented with taking more than 50 mg of 5-HTP which resulted in spurts of euphoria and creativity AND in going to Sibley Hospital’s emergency room twice because it also raised by blood pressure to levels that had me close to fainting.

Many would say that after these experiences I should just stop taking the 5-HTP. But what if that meant having to deal with depression, insomnia and constipation? I decided instead to just take the minimal dose available (50 mg) and to monitor my blood pressure several times each day.

But with my history of addiction and denial, I’ve had what we in AA call “slips” when I violate my no-more-than-50mg rule. I don’t have to go too far back for an example. Several days ago I mistakenly took two 5-HTP pills at bedtime. I woke up with the euphoria and spike in creativity.

But I soon noticed something else. My Parkinson’s symptoms seemed to be lessened. I realized this was real and not imagined when I tried making notes on something I was reading. The Parkinson’s micrographic writing usually makes note taking a waste of time since the writing is so small and cramped that it’s eligible. But this time the writing flowed freely. I kept checking this throughout the day and found that I could use note-taking to map the “on” and “off” levadopa periods. Midway in the pill interval the writing flowed freely. But in the half-hour before and after the pill-taking time the writing returned to small, cramped and barely legible.

I realized the same thing was happening with my walking and balance – almost normal during the “on” times Parkinson’s-afflicted during the “off” times.

I was elated, convinced that I’d accidentally discovered that upping my 5-HTP dosage would have a benign effect on my Parkinson’s symptoms similar to that for depression, insomnia, and constipation. The am blood pressure reading did show a jump with systolic readings in the 160’s and 170’s. But the afternoon readings were back below 150/90.

This led me to think I could get the positive benefits from the increased dose and still keep the blood pressure readings in the normal range if I spread out the extra dose over the day rather than have the bedtime double dose. So I tried that the next day. Unfortunately I got consistently high readings throughout the day and didn’t experience the same enhanced mood, walking, balance and writing that I’d had the day before.


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