If you’re currently taking a blood pressure medication, the chances are pretty good that you’re on one of the ARBs (angiotensin receptor blockers). You can recognize these because they end in -sartan, as in losartan and valsartan.
You also may have heard that two of the most popular ARBs (valsartan and irbesartan) were abruptly withdrawn this year by the FDA and other agencies around the world because they were found to have been tainted with a chemical known to cause cancer in lab animals.
Like many of the prescription drugs we take, these were manufactured in China. Due to a change in manufacturing technique, the carcinogen NDMA was added in 2012. Thus patients taking those two ARBs (other ARBs were not tainted) for the past several years have also been downing a known cancer-causing chemical.
In an attempt to reassure both physicians and patients, an article appeared in the British Medical Journal in which researchers tracked more than 5,000 Danish patients who had used the contaminated meds. Their conclusion was that there was no significant increased cancer risk, but they did urge caution when prescribing them. The response to this study was mixed. Some physicians were relieved, others less so (scroll down at the link for more).
Which raises two important issues
Are doctors overprescribing medication for blood pressure? The answer to that is yes.
Second, has it ever been shown that it’s okay for someone who for years has had well-controlled (with drugs) high blood pressure to go off their meds and see if the body has reset itself and the high blood pressure is, in fact, gone?
Again, the answer is yes as you’ll see below.
If you’re currently taking a blood pressure medication OR your doctor has remarked that she’ll be keeping an eye on your borderline high blood pressure OR high blood pressure runs in your family and you have concerns about it, please read this Health Tip closely. The issues surrounding blood pressure are far more complex than you might guess.
Importantly, your doctor, who we can safely assume intends the best for your health, may be basing her recommendations and prescribing on what, unbeknownst to her, is actually some very controversial information. She simply may not be aware that she’s starting you on what could be decades of inappropriate medication for a condition you don’t really have…and one that isn’t even dangerous to your health.
In fact, based on government guidelines in which your doc is paid less by insurance companies for failing to reach certain clinical goals (like getting your blood pressure down to a designated low number), she may be encouraged to prescribe more meds for your potentially non-existent elevated blood pressure. Read that sentence a couple of times and let it sink in.
It means if your blood pressure is not at a particular “normal” level and your doctor has failed to give you medication to reach that level, she can be financially penalized, even if your actual blood pressure level is totally harmless to your health. Tell me that’s not just a little bit spooky.
What exactly is “normal” blood pressure?
This simple question is actually fraught with controversy, backbiting, scandal, and truly egregious self-serving behavior on the part of highly placed–and highly paid–physicians, drug companies, and apparently neutral organizations like the Food and Drug Administration (FDA) and the World Health Organization (WHO).
For an idea of how the answer to this question has shifted, take a look at this piece.
If you remember what I wrote about statins and high cholesterol–that lowering the number for “ideal cholesterol” meant a multiple million increase in statin users–precisely the same sequence of events has occurred with blood pressure meds.
Over the years there have been numerous studies, all but one financially supported by the pharmaceutical industry, to determine a risk-free blood pressure number. When I was first in training, I learned that blood pressure levels normally rose with a person’s age. The magic formula we were taught? The systolic reading (the top number) was 100 plus your age. The bottom number should be 90 or lower.
Thus, a healthy blood pressure for a 50-year-old could be 150/90. Basically, you started treatment when someone’s blood pressure was 160/100 or higher. I remember one professor saying he preferred 160/95.
But then a series of studies began to appear in the US and Europe saying that the risks for heart disease and stroke increased if that formula (100 + your age) were followed, and the ideal blood pressure was reported as 120/80, with treatment beginning at 140/90. And here’s where the controversy began.
Change the number, create a patient
Although the data did show that patients with consistent blood pressure higher than 140/90 were at some risk for heart attack and stroke, there was not much evidence that using more meds to drive the blood pressure further down–to that magic 120/80–really prevented much of anything. And it certainly increased pill taking, side effects, and symptoms due to blood pressures that actually dropped too low.
From Big Pharma’s perspective, “change the number, create a patient” is an important phrase, possibly a central tenet, as evidenced by these simple equations:
–Bringing total cholesterol down to an “ideal” number anywhere below 200, with an LDL (the bad cholesterol) below 70, hits the financial jackpot. These strict guidelines increase the number of potential statin users from 12.8 to 48 million.
–Adjusting “ideal” blood pressure from 160/100 to 140/90 added 13.5 million new drug users. Trying to medicate people with 140/90 BP to even lower levels adds tens of millions more pill swallowers.
Added to the problem of changing the standards for what constitutes high blood pressure and what does not, doctors are well aware that most people get anxious in the doctor’s office and this itself drives up blood pressure. Called white-coat hypertension, this phenomenon has resulted in tens of thousands of utterly unnecessary blood pressure prescriptions.
I don’t mean now to deliberately trigger your TMJ, but it turns out that virtually every lead investigator of the studies that pushed blood pressure “normals” to lower levels had financial ties to the pharmaceutical industry, as did (and do) the FDA and WHO.
My take on normal blood pressure
So what’s normal? Most doctors agree it depends on the individual’s situation.
Let’s call 145/95 (taken at home, not in the doctor’s office, over a number of days) borderline high blood pressure.
If there are no other risk factors (smoking, being overweight, diabetes, previous heart issues), I begin treatment at this point or higher with a low-salt Mediterranean/ketogenic diet and stress reduction, including yoga, tai chi, or meditation. If there are risk factors such as those noted above, I’ll prescribe a medication and discuss the lifestyle changes outlined below.
Very high blood pressures, like 160/110 or higher, do require prompt pharmacological intervention.
Here’s where the infighting among physicians gets nasty. It turns out that every study with drug money behind it recommended one or more drugs that were newly released at the time and therefore high-priced: beta blockers initially (like Inderal), then angiotensin-converting-enzyme inhibitors (ACE inhibitors such as Lisinopril), angiotensin II receptor blockers (ARBs such as Cozaar), and amlodipine (Norvasc). Obviously, if your doctor is about to write a prescription for ARB, make sure she knows about the cancer link and gets you an untainted version.
But each of these drugs had side effects and were often prescribed in various combinations, increasing the number of possible side effects. Also, driven by that artificially low magic number of 120/80 or lower, some people simply felt crummy having such low blood pressures. The meds don’t magically place you right at 120/80. Sometimes they overshoot the goal. For example, a blood pressure of 90/60 can make many an adult feel woozy and lightheaded.
(This from a patient: “My dad is on three blood pressure meds. He has to stand up real slowly or he gets lightheaded and once he fainted.”)
The only study with no drug money behind it, the ALLHAT study (short for Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), found that the oldest of the blood pressure meds, water pills called diuretics, were the very safest and had the best outcomes for stroke and heart attack prevention.
Yes, there was fury.
Physicians receiving financial largesse from Big Pharma looked mightily for flaws in the ALLHAT study. The drug companies ran full-page ads in the Journal of the American Medical Association basically tweaking ALLHAT data in an attempt to prove their branded drugs were just as good as diuretics.
But they weren’t. Diuretics were best.
With this background, what lifestyle changes can you make?
—If you’re already taking blood pressure meds, work with your doctor when it comes to medication adjustment. Quitting or reducing blood pressure drugs is not a DIY project. If your physician does not recommend going off your meds, ask him or her if you can be switched to a diuretic.
—If you don’t have your own blood pressure measuring device, buy one. It must be one that measures from your upper arm (not your wrist or finger), and if you’re obese be sure to get an extra-wide cuff. Take your blood pressure three to four times weekly at the same time of day. Record all readings and bring them to your doctor. This will eliminate the white-coat hypertension issue.
—Eat along the lines of the Mediterranean diet, which emphasizes veggies, fruits, fish, and poultry (with some whole grains if you can tolerate them) and limits salt, sugar, and red meats. Nibble celery, proven clinically to lower blood pressure.
—If you have severe high blood pressure–diastolic (bottom number) of 110 or higher–and your blood pressure is controlled on meds, stay on them. If you’re on several blood pressure medications and your at-home readings are good, your doc may at least be able to trim the number of meds you take.
—If you have mild high blood pressure and you’re on medication or you’re borderline and your doctor is considering putting you on medication, be proactive. Lose weight, stop smoking, begin regular exercise, and reduce your salt intake. Learn stress reduction techniques such as yoga, meditation, and tai chi. Consider getting (and using!) a portable Resperate unit, the only biofeedback device FDA-approved for high blood pressure.
—If, after your best efforts, you can’t budge your BP below 145/95, try taking two natural products in addition to your medication: Vasophil, containing the amino acid arginine, precursor of nitric oxide, which opens blood vessels (start with one capsule twice daily, increasing to two capsules twice daily if needed) and CoQ10 (UBQH 100 mg daily).
—If you do need a prescription med, start with a diuretic (Hydrochlorothiazide 25 mg daily OR Dyazide one daily OR Furosemide 20 mg daily).
If you had mild high blood pressure to begin with or your blood pressure has been low-normal with meds for years, don’t be reluctant to give your doctor this study, which showed that 25% of patients on blood pressure medication could safely discontinue it (with physician monitoring, of course) and did not have to restart it.
That’s one person out of four taking meds they don’t need. This aligned with a 2003 study that showed one person in five taking these meds could safely discontinue it and remain off it indefinitely.
Don’t be a victim of the several superficially unbiased (but actually highly biased!) organizations that have their best interests, not yours, at heart.
David Edelberg, MD