Common Medications that Pose Increased Risk in Pulmonary Hypertension

Pharmacist trying to fill PAH medication

Non-Steroidal Anti-Inflammatory pain medications (NSAIDS)

Non-Steroidal Anti-Inflammatory pain medications (NSAIDS) such as ibuprofen (Motrin), naproxen (Aleve), Etodolac, celecoxib (Celebrex) are all effective medications for mild to moderate pain.  However, all these medications also put increased stress on your kidneys.  In PAH, the kidneys are already under stress from impaired right heart function.  Taking these medications promotes fluid retention and can lead to abrupt worsening in kidney function and increased shortness of breath over a short period of time.

A safer alternative for mild to moderate pain is acetaminophen (Tylenol).  Even if you have some degree of liver disease, doses of 2,000mg per day are safe.  If you don’t have any liver disease, doses of up to 4,000mg per day are safe.  No more than 1,000mg should be taken at a time and no more often than every 6 hours.  You should avoid alcohol if you take acetaminophen.

Nerve Pain Medications

Medicines for nerve (or neuropathic) pain such as gabapentin (Neurontin) or pregabalin (Lyrica) are now commonly prescribed for fibromyalgia, restless leg syndrome and neuropathy.  They are moderately effective for these conditions.  However, pain specialists often use very high doses of these medications.  Unfortunately, as the dose is increased, these medications have 2 major negative impacts on the rest of your functioning.  First, fluid retention is a major problem with these medications.  At high doses, marked retention of salt and water is the rule not the exception in patients with PAH.  This leads to worsening of your PAH.  Secondly, these medications are very sedating.  Patients tend to be progressively less active and deconditioning may develop.  At lower doses (300mg three times a day or less), these medications may be used safely if you watch your salt and fluid intake, weigh yourself everyday and have regular follow up with your pulmonary hypertension team.

Antibiotics With PAH

Antibiotics are one of the most commonly prescribed medications.  Unfortunately, most antibiotics prescribed for respiratory infections in the ambulatory setting are given to patients with respiratory viruses.  Antibiotics have no activity against viral respiratory infections (except for Tamiflu for Influenza).  At the same time, many PAH patients are taking warfarin (Coumadin).  Antibiotics interact with warfarin in a way that results in warfarin being far more effective.  The net result is that your blood will be too thin and the risk of bleeding will be markedly increased.

The solution to this problem is two-fold.  First, avoid antibiotics for the common cold and other minor respiratory complaints such as acute bronchitis.  Second, if you are taking warfarin, always remind your doctor and ask if the warfarin dose should be reduced.  My practice is to reduce the warfarin dose by 50% for the duration of antibiotic use.  I also check blood work to monitor warfarin more often if the course of antibiotics is prolonged.

Sleeping Pills With Pulmonary Hypertension

Approximately 9 million Americans take sleeping pills.  An estimated 50 million Americans have some trouble sleeping.  Patients with chronic medical problems are more likely to suffer from insomnia.  Although doctors are often well intentioned, we now exist in a culture where we expect to go to sleep immediately and awaken 8 hours later feeling totally refreshed.  This is not a reasonable expectation.  Sleeping pills have a role for a short period of time.  However, regular use often results in dependence.  The FDA recently released an advisory to physicians advising that the maximum dose of zolpidem (Ambien) should be reduced to 5mg for women (6.5mg of the controlled release preparation).  Higher doses of zolpidem result in excessive sedation and can lead to falls at home and negative health consequences.  Patients with obstructive sleep apnea (OSA) who do not use their CPAP device have worsening of their disease when they take sleeping pills.

Tips for Getting a Good Night’s Sleep

The solution to a good night’s sleep lies in the behaviors throughout the day and night.  Below are some tips to help you get a good night’s sleep and avoid regular use of sleeping pills.

1.     Avoid long naps in the afternoon.

2.     Have a set bedtime and wake up time each day.

3.     Allow 8 hours of sleep time.

4.     In the morning, get sun light on your face for at least a few minutes.  An early morning walk is optimal.

5.     If you go to bed and can’t fall asleep, get out of bed and go to another dark room and using a low intensity reading light, read a book or a magazine.

6.     Avoid watching TV or using your computer before bedtime.  Avoid video games before bedtime.

7.     The bedroom should be a relaxing place.  Avoid quarrels with your partner or stressful discussion in the bedroom.

8.     Develop a relaxing routine at bedtime.  Listen to music, meditate or pray.  Avoid ruminating on your troubles at bedtime.