Drug - Nutrient Interactions: Volume 1

Today's e-mail newsletter discusses the interaction between different classes of cardiovascular drugs and nutrients. In today's issue we discuss medication for hypertension (high blood pressure). The next issue will discuss medication for elevated cholesterol, other blood fats such as lipoprotein (a), and other important cardiovascular risk factors such as C-reactive protein.

Choosing a Medication for High Blood Pressure

Choosing a medication, or combination of medications for high blood pressure depends on many factors. Recently it has been discovered that the response from person to person to a particular drug or drug combination for treating high blood pressure can vary remarkably and that a patient's drug protocol must be customized according to their response. Drug side effects and their impact on an individual are another important consideration. If the individual has suffered a stroke or heart attack, if they have asthma, diabetes, kidney disease or other health conditions, and consideration of their age all strongly influence the choice of medication. These and other factors such as cost and patient compliance are considered for the best protocol.

Frequently Asked Questions Concerning High Blood Pressure

What is high blood pressure?

When your heart pumps blood throughout your body, the flow of blood puts pressure on blood vessel walls. This is your blood pressure reading. If the reading goes above a certain level it is referred to as high blood pressure or hypertension. A consistent reading exceeding 140/90 is considered high, a reading of 120/80 is considered average for adults.

Note - this reading measures how high your pressure can push up a column of mercury (the actual measure is in millimeters of mercury or mmHg).

What do the top and bottom figures in my blood pressure reading refer to?

The top figure (measured at 120 for normal) refers to the pressure exerted when the heart pumps out oxygenated blood. It is referred to as systolic pressure. The bottom figure (diastolic pressure) refers to the pressure in between heartbeats. The bottom figure is crucial because the heart has a tiny rest in between beats, if it is elevated the heart is under a lot of stress.

Frequently in older individuals the top figure becomes elevated. This is called isolated systolic hypertension; a typical reading in this case may be 150/80.

Why is high blood pressure dangerous?

High blood pressure is called the "silent killer". This is because high blood pressure often exists without symptoms. Because of this it is important to go for your annual physical. High blood pressure makes the heart work harder and puts a lot of stress directly on the heart muscle. Over time if not controlled, high blood pressure not only affects the heart and blood vessels, but also can lead to damage throughout the body.

Why is high blood pressure dangerous?

If your blood pressure is chronically elevated and is not treated it increases the risk of a number of conditions:

• Stroke: high blood pressure is a leading cause of stroke. It causes bleeding in the brain due to incessant high pressure weakening the walls of blood vessels. High blood pressure also increases the risk of developing a clot which blocks blood flow in the brain.
• Heart Attack: high blood pressure is a major risk for developing a heart attack.
• Damaged blood vessels: consistent elevated pressure hitting the blood vessel walls causes structural damage. The healing process can build up scar tissue on the blood vessel walls narrowing the arteries and increasing the resistance to blood flow.
• Blindness or Impaired Vision: elevated blood pressure in the eye damages the eyes tiny blood vessels causing them to rupture. Vision is eventually decreased. If enough blood vessels burst it can lead to blindness.
• Kidney Damage: High blood pressure can narrow, damage or thicken the blood vessels in the kidneys. The kidneys then have trouble filtering water resulting in a build up of toxins in the body. If damage is excessive, kidney failure occurs and the patient needs to go on dialysis to remove toxins, or eventually receive a kidney transplant.
• Congestive Heart Failure: eventually the heart muscle has to enlarge to compensate for a continuous need to pump harder. At the point where the heart cannot pump enough blood to meet the body's needs, Congestive Heart Failure occurs.

What are some of the risk factors that increase my chances of developing high blood pressure?

Narrowing of the blood vessels is a contributing factor to hypertension, and anything that increases damage to the blood vessel walls eventually can cause cardiovascular disease resulting in hypertension. These conditions include:

• High cholesterol, High LDL-Cholesterol, Low HDL-Cholesterol
• Diabetes
• Smoking
• A diet high in saturated and trans-fats.
• Lifestyle greatly contributes to your risk of developing high blood pressure.

• High salt diet - reduce your salt intake and increase your vegetable, legume, and fruit intake
• Obesity - try to curtail your eating, and avoid calorie dense foods
• Sedentary lifestyle - start walking
• Alcohol - curtail your intake to one or two drinks a day
• Heredity
• Aging
• Smoking - nicotine temporarily constricts blood vessels and causes a temporary elevation of blood pressure, however smoking also causes inflammation of the blood vessels which leads to hardening of the arteries
• Low intake of calcium, magnesium, and potassium

Reducing high blood pressure can save thousands of lives!

Medication for High Blood Pressure

ACE Inhibitors

Examples of commonly prescribed ACE Inhibitors:


• Accupril (quinapril)
• Altace (ramipril)
• Capoten (captopril)
• Lotensin (benazepril)
• Mavik (trandolapril)
• Monopril (fosinopril)
• Prinivil and Zestril (lisinopril)
• Univasc (moexipril)
• Vasotec (enalapril)

Special Instructions

Take ACE inhibitors as scheduled, but on an empty stomach at least one hour before meals.

Activity

The ACE inhibiting family of drugs block the action of an enzyme that causes blood vessels to narrow (constrict). The result is a relaxing and widening (dilation) of your blood vessels allowing blood to flow more easily. ACE Inhibitors also directly block the release of hormones that cause increased retention of sodium and urine.

Relaxation of the blood vessel walls results in many good effects including the following:


• Improves the volume of blood your heart pumps
• Improves the flow of blood
• Decreases the amount of work your heart has to do with each pump, improving the efficiency of the heart muscle
• Decreases your blood pressure (wider blood vessels give less resistance to changes in blood volume, reducing the pressure needed to pump blood)
• Reduces the back up of blood in the heart and lungs
• These drugs also increase the volume of water and sodium released into the urine additionally lowering blood pressure.

Indications

ACE Inhibitors are used for the following reasons:



• High blood pressure
• Heart Failure: lower the risk of death and prolong life of patients with heart failure.
• Some ACE inhibitors if taken soon after a heart attack can decrease the amount of damage done to the heart and improve the odds of surviving
• In diabetics ACE inhibitors slow the process that causes kidney damage.
• In High Risk Individuals ACE Inhibitors decrease the risk of suffering a heart attack or stroke.

Common Side Effects

• Dry irritating cough
• Rash or itchiness
• Loss of taste or a change in the way food tastes
• Swelling of the mouth, face and hands
• Dizziness
• Headache
• Fatigue
• Tingling and numbness
• Orthostatic Hypotension - dizziness when you first stand up
• Increased BUN

Nutrient Interactions:

• ACE inhibitors prevent the excretion of potassium - because of this potassium levels in the body can build up to a dangerous level: if you are on an ACE inhibitor you need to have your blood potassium levels checked regularly; do not take potassium supplements or use salt substitutes without speaking to your doctor (salt substitutes usually contain potassium).
• ACE inhibitors deplete zinc: make sure you are taking a zinc containing multiple-vitamin, mineral supplement.
• Iron supplements block the absorption of captopril - if you need to take iron, take the iron supplement at least 3 hours after taking captopril
• Iron supplements may reduce the incidence of coughing commonly caused by ACE inhibitors

Alpha-Adrenergic Blocking Agents

Examples of commonly prescribed Alpha Blockers:


• Cardura (doxazosin)
• Hytrin (terazosin)
• Minipress (prazosin)
• Flomax (tamsulosin) is used for benign prostatic hyperplasia (BPH)

Caution:

A major study of almost 25,000 patients using Cardura was stopped abruptly by the advisory committee from the National Heart, Lung, and Blood Pressure Institute, the sponsor of the study, when the drug was associated with a higher risk of stroke, chest pain, and congestive heart failure when compared with a diuretic. The patients using Cardura had 25% more heart problems and were twice as likely to be hospitalized for heart failure than patients using the diuretic chlorthalidone. The patients on Cardura also had slightly higher blood pressure. It is not yet known if the Cardura was less protective than the diuretic or if it actually increases risk of these conditions (stroke, chest pain, congestive heart failure).

Currently Alpha-Adrenergic Blockers are still used for high blood pressure if no other drug is effective.

Special Caution:

Never discontinue using any high blood pressure medication without discussing it with your doctor; sudden discontinuation of these drugs can be very dangerous.



Angiotensin II Receptor Blockers (ARBs)

Examples of commonly prescribed ARBs:


• Atacand (candesartan)
• Avapro (irbesartan)
• Cozaar, Hyzaar (losartan)
• Diovan (valsartan)
• Teveten (eprosartan)
• Trovan (aprosartan)

Special Instructions
May be taken with or without food.

Activity

Similar mechanism of action as ACE inhibitors, reducing blood pressure as effectively, but with fewer side effects (they do not cause a cough, a common side effect of ACE inhibitors, and a reason why many people stop taking ACE inhibitors).



• ARBs do not cause a cough, patients taking ACE inhibitors who develop a cough are often switched to ARBs
• ARBs may decrease the risk of stroke and heart attack in people with a high risk of high blood pressure complications ((losartan was more effective than the Beta-Blocking drug atenolol in a study).
• Losartan may be more effective than atenolol for preventing a heart attack or stroke in diabetics.
• ARBs have not been studied to examine if they decrease the risk of dying in patients with heart failure (ACE inhibitors have already been studied for this condition).
• Losartan was more effective than the Beta-Blocking drug atenolol in patients with isolated systolic hypertension, and with left ventricular hypertrophy.

Indications for people who cannot tolerate ACE Inhibitors
• High blood pressure
• Heart Failure

Side Effects
• Headache
• Dizziness
• Nasal congestion
• Can worsen kidney function in patients with reduced kidney function

Nutrient Interactions
• ARBs decrease the excretion of potassium: do not take potassium supplements or potassium containing salt substitutes before speaking with your doctor.

Beta-Adrenergic Blocking Agents

Examples of commonly prescribed Beta-Blockers:


• Corgard (nadolol)
• Coreg (carvedilol)
• Inderal (propranolol)
• Kerlone (betaxolol)
• Lopressor, Toprol XL (metoprolol)
• Normodyne, Trandate (labetalol)
• Sectral (acebutolol)
• Tenormin (atenolol)
• Visken (pindolol)
• Zebeta (bisoprolol)

Special Instructions
Take Beta-Blockers with food or immediately after eating.

Activity
Beta-Blocking Drugs improve the hearts ability to relax.


• Beta-Blockers slow the heart down (decrease the heart rate) and allow it to fill more completely before beating
• They improve the percentage of blood pumped from the left ventricle with each heartbeat improving ejection fraction
• Over time they improve the hearts ability to pump blood
• They slow the progression of heart failure
• They decrease the risk of dying from a heart attack or heart failure
• They lower blood pressure

Indications
Beta-Blockers are used for:


• High blood pressure
• Reducing the risk of heart disease, stroke, heart attack, and sudden death in people with heart disease
• Decreasing the risk of death from heart disease (21%), from stroke (38%), from Coronary Artery Disease (16%)
• Heart Failure
• Arrhythmias
• Individuals with high blood pressure who have had a heart attack
• Individuals with both high blood pressure and angina

Sometimes Beta-Blockers are used for other conditions including:

• Anxiety
• Tremors
• Migraine headaches

Common Side Effects

• Slow heart rate
• Nightmares, vivid dreams
• Fatigue, lethargy
• Depression
• Memory loss
• Dizziness, Orthostatic Hypotension (dizziness when first standing)
• Cold hands and feet
• Decreased endurance
• Possible increased risk of developing type 2 diabetes
• Increased blood sugar
• Difficulty in breathing
• Worsening of asthma, emphysema, chronic bronchitis, COPD
• Decreased HDL levels; the beneficial blood fat (possibly lowered by 10%, especially in smokers)
• Difficulty in loosing weight
• In older patients Beta-Blockers can decrease the hearts output

Nutrient Interactions

• Beta-Blockers can bind to calcium and decrease its absorption; take calcium supplements at a different time than your Beta-Blocker (two hours apart minimally)
• Beta-Blockers decrease the activity of Coenzyme Q10, and can also decrease its blood levels; you may need to supplement with coenzyme Q10 - discuss this with your health professional
• Beta-Blockers can decrease HDL levels (the protective cholesterol); chromium supplementation may prevent this effect.

Calcium Channel Blocking Drugs (CCBs)

Examples of commonly prescribed Calcium Channel Blockers:


• Adalat, Procardia (nifedipine)
• Cardene (nicardipine)
• Cardizem (diltiazem)
• Norvasc (amlodipine)
• Plendil (felodipine)
• Calan, Isoptin, Verelan (verapamil)
• Sular (nisoldipine)
• DynaCirc (isradipine)

Special Instructions Swallow with liquid, take verapamil with food.

Activity CCBs work by reducing the amount of constriction, or narrowing, of the blood vessels caused by high blood pressure, making blood flow through these vessels easier. As a result they decrease blood pressure immediately. Diltiazem and verapamil also decrease the heart rate and have an effect on the hearts blood pumping ability.

Indications
• High blood pressure
• May help control angina in patients with high blood pressure and coronary artery disease
• Helpful for people who have a hard time decreasing their salt intake
• Older adults with high blood pressure
• Migraine treatment
Common Side Effects
• Tiredness
• Dizziness
• Facial flushing
• Headache
• Difficult urination
• Swollen ankles, legs, and feet
• Shortness of breath, wheezing, coughing,
• Peripheral edema (fluid buildup in the legs)
• Numbness and tingling of the hands
• Rapid Heart Beat
• Slow Heart Beat (verapamil, diltiazem)
• Some CCBs may actually increase the risk of heart failure
• Constipation
• Impotence
• Gingivitis
Nutrient Interactions
• Excessive amounts of calcium may hypothetically decrease the effectiveness of CCBs
• Grapefruit juice boosts the effect of CCBs and it should be avoided
• Seville Oranges often used in marmalade can increase the effect of CCBs and should be avoided

Diuretics

There are primarily 3 types of diuretics, and all 3 deplete important nutrients. For many decades, diuretics have been the corner stone of high blood pressure therapy and diuretics remain the drugs of choice for many people with high blood pressure. In fact a recent study shows that people who take diuretics have a lower risk of developing heart disease, stroke, and heart failure than people who took an ACE inhibitor or a Calcium Channel Blocker. A previous analysis of studies demonstrated that diuretics reduced the risk of heart attack, stroke, and death better than a Beta-Blocking drug.

Diuretics work by increasing your excretion of salt and water in the urine. Diuretics are an important choice for older adults because of their reliability and decreased toxicity. They have been shown to decrease the risk of stroke and they may be the best drug class used to treat hypertension for protecting against stroke. They may even decrease the risk of dementia (senile memory loss). They decrease the risk of heart attack and may also decrease the risk of blood clots.

Please note, while on diuretics your physician should periodically monitor your blood electrolytes for imbalances.

Loop Diuretics

Examples of commonly prescribed loop diuretics:


• Bumex (bumetadine)
• Edecrin (ethacrynic acid)
• Lasix (furosemide)
Loop Diuretics are the strongest diuretics.
Loop diuretics deplete the minerals Calcium, Magnesium, Potassium, and Zinc. They also deplete important vitamins, B1, B6 and Vitamin C. Supplementation is necessary to replete these important nutrients.

Special Note - if the depleted level of potassium remains untreated it can lead to an increased risk of cardiac arrhythmias.

Symptoms of low potassium include muscle cramps and an irregular heart beat.

Thiazide Diuretics

Examples of commonly prescribed Thiazide diuretics:


• Diuril (chlorothiazide)
• HydroDiuril, Esidrix (hydrochlorothiazide)
• Hygroton (chlorthalidone)
• Zaroxolyn (metolazone)
Thiazide diuretics are often used alone to treat mild to moderate hypertension or they can be used in combination with other drugs. They are useful for isolated systolic hypertension, edema (swelling due to water retention) associated with heart failure, and for Nephrotic syndrome.

Thiazide diuretics deplete the minerals Calcium, Magnesium, Potassium, and Zinc. They also deplete vitamin D, vitamin B6, and coenzyme Q10. Supplementation is necessary to replete these important nutrients.

Special Note - if the depleted level of potassium remains untreated it can lead to an increased risk of cardiac arrhythmias.

Symptoms of low potassium include muscle cramps and an irregular heart beat.

Potassium Sparing Diuretics

Examples of commonly prescribed potassium sparing diuretics:


• Aldactone (spironolactone)
• Dyrenium (triamterene)
• Midamor (amiloride)
Potassium sparing diuretics are used for high blood pressure, and for patients with heart failure. Spironolactone is often used for severe heart failure.

Potassium sparing diuretics deplete the minerals calcium and zinc, and the important B complex vitamin, folic acid. Supplementation is necessary to replete these important nutrients.

Potassium sparing diuretics reduce the urinary loss of potassium. Potassium levels can build up in the body. Excess potassium can be dangerous and the bloods potassium levels should be monitored. Do not take potassium supplements or salt substitutes containing potassium while on these drugs.

Common Side Effects of All Three Families of Diuretics

• Increased thirst
• Low blood pressure due to dehydration
• Increased risk of heat exhaustion
• Increased blood fats, blood sugar, and uric acid
• Fatigue
• Depression
• Irritability

Nutrients useful for patients with high blood pressure

Many nutrients are useful adjuncts for individuals with hypertension and you may want to discuss the following with your physician:


• Magnesium
• Potassium (do not take with ACE Inhibitors, ARBs, or Potassium Sparing Diuretics)
• Taurine
• Coenzyme Q10; this nutrient may be especially beneficial for patients with isolated systolic hypertension.
• L-Carnitine
• L-Arginine
• Fish Oil Capsules
• Aged Garlic Extract
• Grape Seed Extract
• Hawthorne Leaf Extract
• A good Multiple-Vitamin and Mineral Supplement to replace the nutrients depleted by anti-hypertensive drugs.
• L-Theanine
• Olive Leaf Extract