hydralazine hydrochloride - PDR.Net

2024-11-15

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Hydralazine is contraindicated in patients with mitral valve rheumatic heart disease because it can increase pulmonary artery pressure. PDRSearch typedrugnamehere... Requiredfield Home / HydralazineHydrochlorideTabletsDrugInformation / DrugSummary email print Closewindow Emailthispage Sendthepage"" toafriend,relative,colleagueoryourself. YourName Recipient'sEmail Separatemultipleemailaddresswithacomma Message Wedonotrecordanypersonalinformationenteredabove. Cancel Thankyou.Youremailhasbeensent. Close Advertisement hydralazinehydrochloride-DrugSummary JumptoSection CLASSES DEACLASS DESCRIPTION COMMONBRANDNAMES HOWSUPPLIED ViewAllSections... DOSAGE&INDICATIONS MAXIMUMDOSAGE DOSINGCONSIDERATIONS ADMINISTRATION STORAGE CONTRAINDICATIONS/PRECAUTIONS ADVERSEREACTIONS DRUGINTERACTIONS PREGNANCYANDLACTATION MECHANISMOFACTION PHARMACOKINETICS ViewLessSections... Advertisement RelatedDrugInformation DrugSummary CLASSES PeripheralVasodilators,Plain DEACLASS Rx DESCRIPTION Oralandparenteralvasodilator;usedforHTNandCHF,althoughACEinhibitorshavelargelyreplacedhydralazineforCHF;usedforHTNduringpregnancy;alsousedtotreatpulmonaryhypertension;itsuseinthegeneralpopulationforHTNhasdeclinedduetoadverseeffectsandtachyphylaxis. COMMONBRANDNAMES Apresoline HOWSUPPLIED Apresoline/HydralazineHydrochlorideOralTab:10mg,25mg,50mg,100mgHydralazineHydrochlorideIntramuscularInjSol:1mL,20mgHydralazineHydrochlorideIntravenousInjSol:1mL,20mg DOSAGE&INDICATIONS Forthetreatmentofhypertension.OraldosageAdultsInitially,10mgPO4timesdailyforthefirst2—4days,increaseto25mgPO4timesdailyforthebalanceofthefirstweek.Forthesecondandsubsequentweeks,increasedosageto50mgPO4timesdaily;titratetolowesteffectivedosageforbloodpressurecontrol.Althoughaninitialdoseof10mgisrecommended,duetothesignificantfirst-passeffectofhydralazine,initialdosesof25mgareusuallysafe.Maximumrecommendeddosageis300mg/dayPO;however,theincidenceofsystemiclupuserythematosusishigherinpatientsreceivinghigherdoses(e.g.,>200—400mg/dayPO).Infants†,Children†,andAdolescents†Initially,0.75mg/kg/dayPO,givenin4divideddoses.Maximuminitialdosageis25mg/dose.Titrateover3—4weeksuptoamaximumof7.5mg/kg/dayPO(nottoexceed200mg/dayPO).Neonates†Limiteddatainneonates.However,0.25—1mg/kg/dosePOadministered3—4timesdailyhasbeensuggested.Graduallyincreaseasneededforbloodpressurecontroltoamaximumdosageof7.5mg/kg/dayPO.IntravenousRouteAdults10—20mgIVbolus.Repeatasneeded,usuallyevery4—6hours.Switchtooralantihypertensivetherapyassoonaspossible,usuallywithin24—48hours.WhenswitchingfromIVtooraltherapy,theIVdoseshouldgenerallybedoubledandadministeredorally;titratetheoraldosetoresponse.Infants†,Children†,andAdolescents†Initially,0.2—0.6mg/kg/doseIV(upto20mg)every4hoursasneededforbloodpressurecontrol.Max:1.7—3.5mg/kg/dayIV,givenindivideddosesevery4hoursasneeded.UseIVrouteonlyifPOisnotfeasible.Switchtooraltherapyassoonaspossible,usuallywith24—48hours.WhenswitchingfromIVtooraltherapy,theIVdoseshouldgenerallybedoubledandadministeredorally;titratetheoraldosetoresponse.Neonates†Limiteddatainneonates.Adoseof0.15—0.6mg/kg/doseIVadministeredevery4hourshasbeensuggested.Repeatasneededforbloodpressurecontrol.OnlyuseIVrouteifPOisnotfeasible.Switchtooralantihypertensivetherapyassoonaspossible,usuallywithin24—48hours.WhenswitchingfromIVtooraltherapy,theIVdoseshouldgenerallybedoubledandadministeredorally;titratetheoraldosetoresponse.IntramusculardosageAdults10—50mgIM.Repeatasneeded,usuallyevery4—6hoursinitially.Switchtooralantihypertensivetherapyassoonaspossible,usuallywithin24—48hours.Infants†,Children†,andAdolescents†Initially,0.2—0.6mg/kg/doseIM(upto20mg)every4hoursasneededforbloodpressurecontrol.Max:1.7—3.5mg/kg/dayIM,givenindivideddosesevery4hoursasneeded.UseIMrouteonlyifPOorIVisnotfeasible.Switchtooraltherapyassoonaspossible,usuallywith24—48hours.Forthetreatmentofhypertensiveemergencyorhypertensiveurgency.Forthetreatmentofhypertensionassociatedwithseverepreeclampsiaoreclampsia.IntravenousdosageAdultfemales5to10mgIVover2minutesforSBPof160ormoreorDBPof110ormoremmHg.CheckBPin20minutesandifeitherBPthresholdisexceeded,give10mgIVover2minutes.CheckBPin20minutesandifeitherthresholdisexceeded,switchtolabetalol20mgIVover2minutesandcheckBPin10minutes.IfeitherBPthresholdisstillexceeded,givelabetalol40mgIVover2minutes,obtainemergencyconsultation,andgiveadditionalantihypertensivemedicationperspecificorder.OnceSBPislessthan160andDBPislessthan110,checkBPevery10minutesfor1hour,thenevery15minutesfor1hour,thenevery30minutesfor1hour,andthenonceeveryhourfor4hours.IntravenousdosageAdultsInitially,10to20mgIVbolus.Repeatasneeded,usuallyevery4to6hours.Switchtooralantihypertensivetherapyassoonaspossible,usuallywithin24to48hours.WhenswitchingfromIVtooraltherapy,theIVdoseshouldgenerallybedoubledandadministeredorally;titratetheoraldosetoresponse.Infants†,Children†,andAdolescents†0.1to0.2mg/kg/doseIVevery4hoursasneededforbloodpressurecontrol.Max:0.4mg/kg/dose,upto20mg/dose.Switchtooraltherapyassoonaspossible,usuallywithin24to48hours.WhenswitchingfromIVtooraltherapy,theIVdoseshouldgenerallybedoubledandadministeredorally;titratetheoraldosetoresponse.Neonates†Limiteddatainneonates.Adoseof0.15to0.6mg/kg/doseIVadministeredevery4hourshasbeensuggested.Repeatasneededforbloodpressurecontrol.Switchtooralantihypertensivetherapyassoonaspossible,usuallywithin24to48hours.WhenswitchingfromIVtooraltherapy,theIVdoseshouldgenerallybedoubledandadministeredorally;titratetheoraldosetoresponse.IntramusculardosageAdultsInitially,10to50mgIM.Repeatasneeded,usuallyevery4to6hoursinitially.Switchtooralantihypertensivetherapyassoonaspossible,usuallywithin24to48hours.Infants†,Children†,andAdolescents†0.1to0.2mg/kg/doseIMevery4hoursasneededforbloodpressurecontrol.Max:0.4mg/kg/dose,upto20mg/dose.Switchtooraltherapyassoonaspossible,usuallywithin24to48hours.OraldosageChildren†andAdolescents†0.25mg/kg/dose(Max:25mg/dose)POevery6to8hoursasneededisrecommendedforseverelyhypertensivepatientswithnon-life-threateningsymptoms.Forthetreatmentofheartfailure†.OraldosageAdultsInitially,25to50mgPO3to4timesdaily.Dosagemaybeincreasedweekly(e.g.,by25mg/dose)toatargetdoseof100mgPO3timesdaily.Guidelinesrecommendhydralazineplusisosorbidedinitrateincombinationwithangiotensin-convertingenzyme(ACE)inhibitor,angiotensinreceptorblocker(ARB),orangiotensinreceptor-neprilysininhibitor(ARNI)forblackpatientswithreducedejectionfractionheartfailure(HFrEF)NYHAclassIIIorIVtoreducemorbidityandmortality.ThecombinationofisosorbidedinitrateandhydralazinewithanARNIhasnotbeenrobustlytested;bloodpressureresponseshouldbecarefullymonitored.Infants,Children,andAdolescents0.25to1mg/kg/dosePOevery6to8hours.Increasedoseasneeded.Maximumdoseis7mg/kg/dayPO.Theincidenceofsystemiclupuserythematosusishigherinpatientsreceivingdosesmorethan200mg/day.IntravenousdosageInfants,Children,andAdolescents0.1to0.5mg/kg/doseIVevery6to8hours.Switchtooraltherapyassoonaspossible.†Indicatesoff-labeluse MAXIMUMDOSAGE Adults300mg/dayPOforhypertension.Higherdoseshavebeenusedtotreatpatientswithheartfailure;however,dosesgreaterthan200—300mg/dayPOareassociatedwithahigherriskofdrug-inducedsystemiclupuserythematosus.TitrateIVandIMdosageasneededforbloodpressurecontrol.Geriatric300mg/dayPOforhypertension.Higherdoseshavebeenusedtotreatpatientswithheartfailure;however,dosesgreaterthan200—300mg/dayPOareassociatedwithahigherriskofdrug-inducedsystemiclupuserythematosus.TitrateIVandIMdosageasneededforbloodpressurecontrol.AdolescentsSafetyandefficacynotestablished;however,dosesupto7.5mg/kg/dayPOor200mg/dayPO,whicheverisless,or3.5mg/kg/dayIVorIMhavebeenused.ChildrenSafetyandefficacynotestablished;however,dosesupto7.5mg/kg/dayPOor200mg/dayPO,whicheverisless,or3.5mg/kg/dayIVorIMhavebeenused.InfantsSafetyandefficacynotestablished;however,dosesupto7.5mg/kg/dayPOor3.5mg/kg/dayIVorIMhavebeenused.NeonatesSafetyandefficacynotestablished;however,dosesupto7.5mg/kg/dayPOor0.6mg/kg/doseIVhavebeenused. DOSINGCONSIDERATIONS HepaticImpairmentSpecificguidelinesfordosageadjustmentsinhepaticimpairmentarenotavailable.Hydralazineisextensivelymetabolizedintheliverandissubjecttopolymorphicacetylation;patientswithslowacetylationstatushavehigherplasmalevelsofhydralazineandthesepatientsrequirelowerdosestomaintaincontrolofbloodpressure.RenalImpairmentCrCl>50mL/min:nodosageadjustmentneeded.CrCl10—50mL/min:administerevery8hours.CrCl<10mL/min:administerevery8—16hours.Intervalmaybeextendedto12—24hoursbasedonpatientresponse. IntermittentHemodialysis:Administerevery12to24hoursdependingonpatientbloodpressure. PeritonealDialysis:Administerevery12to24hoursdependingonpatientbloodpressure. ADMINISTRATION OralAdministrationAdministerconsistentlywithregardstotimingaroundmeals/foodtoensureconsistentoralabsorptionofhydralazine.InjectableAdministrationHydralazinecanbeadministeredintramuscularlyorasarapidIVinjection.DonotaddhydralazinetoanyIVsolutions.Visuallyinspectparenteralproductsforparticulatematteranddiscolorationpriortoadministrationwheneversolutionandcontainerpermit.Administerdoseimmediatelyafteropeningthevial.Hydralazinechangescoloraftercontactwithmetal,discardanydiscoloredhydralazinesolution.Bloodpressureshouldbecheckedfrequentlyfollowingadministrationofinjectablehydralazine.IntravenousAdministrationInjectundilutedinjectionIVviaY-siteora3-waystopcockatarateof10mgoveratleast1minute.IntramuscularAdministrationNodilutionnecessary.Injectdeeplyintoalargemuscle.Aspiratepriortoinjectiontoavoidinjectionintoabloodvessel. STORAGE Generic:-Discardproductifitcontainsparticulatematter,iscloudy,ordiscolored-Discardunusedportion.Donotstoreforlateruse.-Protectfromdirectsunlight-Storeatcontrolledroomtemperature(between68and77degreesF)-Storeinacool,wellventilated,dryplace-StoreinoriginalcontainerApresoline:-Storebetween68to77degreesF,excursionspermitted59to86degreesF CONTRAINDICATIONS/PRECAUTIONS Slowacetylation,systemiclupuserythematosus(SLE)Hydralazinemayproduceaclinicalpicturesimulatingsystemiclupuserythematosus(SLE)includingglomerulonephritis.Hydralazineundergoesextensivehepaticmetabolism;itisexcretedmainlyintheformofmetabolitesintheurine.Hydralazineissubjecttopolymorphicacetylation;slowacetylationstatusresultsinhigherplasmalevelsofhydralazineandthesepatientsrequirelowerdosestomaintaincontrolofbloodpressure.Thus,thepatient'sacetylationphenotypewillaffecttheplasmaconcentrationofhydralazine.Patientswhoareslowacetylatorsaswellaspatientswithdecreasedrenalfunctionaremorelikelythanfastacetylatorstodeveloplupus-likesymptomsorpotentiallyotherhydralazinetoxicity.Patientswithdecreasedrenalfunction,patientsreceivingmorethan200mg/day,andpatientswithafamilyhistoryofautoimmunediseasearealsomorelikelytodevelopthiscondition.Itisdifficulttoprovideguidelinesregardingadministrationofhydralazinetopatientswithpreexistingsystemiclupuserythematosus(SLE).Althoughhydralazinehasbeenadministeredsafelytothesepatients,withnoexacerbationofunderlyingdisease,andthemechanismofhydralazine-inducedlupussyndromeappearstobedistinctfromidiopathiclupus,hydralazineshouldneverthelessbeusedcautiouslyinthispopulation.Completebloodcountsandantinuclearantibodytiterdeterminationsareindicatedbeforeandperiodicallyduringprolongedtherapy,evenifthepatientdoesnothaveanysymptoms;thesetestsarealsoindicatedifapatientsdevelopsarthralgia,fever,chestpain,continuedmalaise,orotherunexplainedsymptoms.Ifhydralazine-inducedSLEoccurs,thedrugshouldbediscontinued,unlessthebenefitofcontinuedantihypertensivetherapywiththisdrugoutweighstherisk.Signsandsymptomsoflupususuallyregresswhenthedrugisdiscontinued;however,residualsignsandsymptomshavebeendetectedmanyyearslater.Long-termtreatmentwithsystemicsteroidsmaybenecessary.Renalfailure,renalimpairmentHydralazineundergoesextensivehepaticmetabolism;itisexcretedmainlyintheformofmetabolitesintheurine.Inhypertensivepatientswithnormalkidneyswhoaretreatedwithhydralazine,thereisevidenceofincreasedrenalbloodflowandamaintenanceofglomerularfiltrationrate(GFR).Insomeinstanceswherecontrolvalueswerebelownormal,improvedrenalfunctionhasbeennotedafteradministrationofthedrug.However,aswithanyantihypertensiveagent,hydralazineshouldbeusedwithcautioninpatientswithadvancedrenaldamage.Somereferencesstatetoconsiderextendeddoseintervalsinpatientswithrenalimpairment(CrCl10to50mL/min).Patientswithrenalimpairmentshouldreceivethedrugevery8hours.Patientswithrenalfailure(CrCllessthan10mL/min)shouldreceivethedrugevery8to16hours;basedonpatientresponse,intervalsof12to24hoursmaybeneeded.Acutemyocardialinfarction,angina,coronaryarterydisease,heartfailure,myocardialinfarction,rheumaticheartdiseaseHydralazineiscontraindicatedinpatientswithmitralvalverheumaticheartdiseasebecauseitcanincreasepulmonaryarterypressure.Additionally,ithasbeenimplicatedincausinganginaandmyocardialinfarctionsecondarytoreflexsympatheticnervoussystemstimulation(i.e.,reflextachycardia);therefore,hydralazineiscontraindicatedinpatientswithcoronaryarterydiseaseasreflextachycardiaincreasesmyocardialoxygendemandandcanaggravateanginaandischemiaandprecipitateacutemyocardialinfarction.Usehydralazinecautiouslyinpatientswithanaorticaneurysm.Becausehydralazinecancausesodiumandfluidretention,itsuseisgenerallynotrecommendedinpatientswithcongestiveheartfailure,althoughithasbeenusedinpatientswithintractableleftventriculardysfunction.However,whenusedwithisosorbidedinitrate,this2-drugcombinationisconsideredtobeanappropriatealternativetopatientswhocannottoleratestandardheartfailuretherapy,mainlyangiotensinconvertingenzyme(ACE)inhibitors.Furthermore,combinationtherapyofisosorbidedinitrateandhydralazine,inconjunctionwithstandardtherapy,hasbeenshowntoimprovemortality,rateoffirsthospitalizations,andqualityoflifeinblackpatients;afixed-dosecombinationofisosorbidedinitrateandhydralazine(BiDIl)isFDA-approvedforthetreatmentofheartfailureinblackpatients.Increasedintracranialpressure,strokeUsehydralazinecautiouslyinpatientswithacutestrokeorcerebralvascularaccidentashydralazineinthissettingcanfurtherworsenbrainfunction.Whenhydralazineisusedinthepresenceofincreasedintracranialpressure,loweringofthebloodpressuremayresultinincreasedcerebralischemia.PregnancyTherearenoadequateandwell-controlledstudiesinpregnantwomen.Althoughclinicalexperiencedoesnotidentifyevidenceoffetaladverseeffects,usehydralazineduringpregnancyonlyiftheexpectedbenefitoutweighsthepotentialrisktothefetus.Intravenoushydralazineiscommonlyusedforacute-onsetseverehypertensioninpregnancy.Animalstudiesindicatethathydralazineisteratogenicinmiceat20to30timesthemaximumdailydoseof200to300mgandpossiblyinrabbitsat10to15timesthemaximumdailyhumandose,butthatitisnonteratogenicinrats.Teratogeniceffectsobservedwerecleftpalateandmalformationsoffacialandcranialbones.Breast-feedingUsecautionwhenadministeringhydralazinetoabreast-feedingwoman.PreviousAmericanAcademyofPediatrics(AAP)recommendationsconsideredhydralazinetobegenerallycompatiblewithbreast-feeding.Hydralazineisdistributedintohumanmilk.Inacasereportofamothertakinghydralazine50mgPO3timesdaily,hydralazinebreastmilkconcentrationswere130mcg/Lat0.5and2hoursafteradose.Basedontheseconcentrations,itisestimatedthatanursinginfantwouldreceive13mcgofhydralazineper75mLofbreastmilk.DrivingoroperatingmachineryHydralazinecaninducedisorientationorconfusion.Patientsshouldusecautionwhendrivingoroperatingmachineryuntiltheyareawareoftheeffectsofthemedication.GeriatricClinicalexperiencehasnotidentifieddifferencesinresponsestohydralazinebetweengeriatricandyoungeradultpatients.Hydralazinemaybeeliminatedmoreslowlyingeriatricpatients.Whendosinghydralazineintheelderly,itmaybeprudenttostartthedoseatthelowendofthedosingrangeandmonitorthepatientscloselyforhypotensiveeffects.Subsequentdosageadjustmentsshouldbemadebasedonclinicalresponse.ThefederalOmnibusBudgetReconciliationAct(OBRA)regulatesmedicationuseinresidentsoflong-termcarefacilities(LTCFs).TheOBRAguidelinescautionthatnitratesmaycauseheadaches,dizziness,lightheadedness,faintness,orsymptomaticorthostatichypotension,particularlywheninitiallystartedorwhentakenwithantihypertensives.[60742]ThefederalOmnibusBudgetReconciliationAct(OBRA)regulatesmedicationuseinresidentsoflong-termcarefacilities(LTCFs).AccordingtoOBRA,antihypertensiveregimensshouldbeindividualizedtoachievethedesiredoutcomewhileminimizingadverseeffects.Antihypertensivesmaycausedizziness,posturalhypotension,fatigue,andthereisanincreasedriskforfalls.Therearemanydruginteractionsthatcanpotentiatetheeffectsofantihypertensives.Someagentsrequireagradualtapertoavoidadverseconsequencescausedbyabruptdiscontinuation. ADVERSEREACTIONS Severemyocardialinfarction/Delayed/Incidencenotknownileus/Delayed/Incidencenotknownpericarditis/Delayed/Incidencenotknownglomerulonephritis/Delayed/Incidencenotknownvasculitis/Delayed/Incidencenotknownlupus-likesymptoms/Delayed/Incidencenotknownagranulocytosis/Delayed/IncidencenotknownModerateangina/Early/1.0-10.0sinustachycardia/Rapid/10.0palpitations/Early/10.0edema/Delayed/Incidencenotknownhypotension/Rapid/Incidencenotknownperipheraledema/Delayed/Incidencenotknownperipheralvasodilation/Rapid/Incidencenotknownorthostatichypotension/Delayed/Incidencenotknownfluidretention/Delayed/Incidencenotknownconstipation/Delayed/Incidencenotknownerythema/Early/Incidencenotknownhepatitis/Delayed/Incidencenotknowneosinophilia/Delayed/Incidencenotknownperipheralneuropathy/Delayed/Incidencenotknownleukopenia/Delayed/Incidencenotknownanemia/Delayed/Incidencenotknowndyspnea/Early/Incidencenotknownsplenomegaly/Delayed/Incidencenotknownconjunctivitis/Delayed/Incidencenotknownlymphadenopathy/Delayed/Incidencenotknowndepression/Delayed/Incidencenotknownconfusion/Early/IncidencenotknownMilddiarrhea/Early/1.0-10.0vomiting/Early/1.0-10.0anorexia/Delayed/1.0-10.0nausea/Early/10.0headache/Early/10.0syncope/Early/Incidencenotknowndizziness/Early/Incidencenotknownweightgain/Delayed/Incidencenotknownchills/Rapid/Incidencenotknownweakness/Early/Incidencenotknownarthralgia/Delayed/Incidencenotknownpruritus/Rapid/Incidencenotknownurticaria/Rapid/Incidencenotknownmyalgia/Early/Incidencenotknownrash/Early/Incidencenotknownfever/Early/Incidencenotknownparesthesias/Delayed/Incidencenotknownpurpura/Delayed/Incidencenotknowntremor/Early/Incidencenotknownlacrimation/Early/Incidencenotknownnasalcongestion/Early/Incidencenotknownflushing/Rapid/Incidencenotknownmusclecramps/Delayed/Incidencenotknownanxiety/Delayed/Incidencenotknown DRUGINTERACTIONS Acetaminophen;Chlorpheniramine;Dextromethorphan;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Chlorpheniramine;Dextromethorphan;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Chlorpheniramine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Chlorpheniramine;Phenylephrine;Phenyltoloxamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Dextromethorphan;Guaifenesin;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Dextromethorphan;Guaifenesin;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Dextromethorphan;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Dextromethorphan;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Dichloralphenazone;Isometheptene:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Guaifenesin;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acetaminophen;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Acrivastine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Aldesleukin,IL-2:(Moderate)Vasodilatorsmaypotentiatethehypotensionseenwithaldesleukin,IL2.Alemtuzumab:(Moderate)Alemtuzumabmaycausehypotension.Carefulmonitoringofbloodpressureandhypotensivesymptomsisrecommendedespeciallyinpatientswithischemicheartdiseaseandinpatientsonantihypertensiveagents.Aliskiren:(Moderate)Aliskirencanenhancetheeffectsofvasodilatorsonbloodpressureifgivenconcomitantly.Thisadditiveeffectmaybedesirable,butdosagesmustbeadjustedaccordingly.Bloodpressureandelectrolytesshouldberoutinelymonitoredinpatientsreceivingaliskiren.Aliskiren;Amlodipine:(Moderate)Aliskirencanenhancetheeffectsofvasodilatorsonbloodpressureifgivenconcomitantly.Thisadditiveeffectmaybedesirable,butdosagesmustbeadjustedaccordingly.Bloodpressureandelectrolytesshouldberoutinelymonitoredinpatientsreceivingaliskiren.Aliskiren;Amlodipine;Hydrochlorothiazide,HCTZ:(Moderate)Aliskirencanenhancetheeffectsofvasodilatorsonbloodpressureifgivenconcomitantly.Thisadditiveeffectmaybedesirable,butdosagesmustbeadjustedaccordingly.Bloodpressureandelectrolytesshouldberoutinelymonitoredinpatientsreceivingaliskiren.Aliskiren;Hydrochlorothiazide,HCTZ:(Moderate)Aliskirencanenhancetheeffectsofvasodilatorsonbloodpressureifgivenconcomitantly.Thisadditiveeffectmaybedesirable,butdosagesmustbeadjustedaccordingly.Bloodpressureandelectrolytesshouldberoutinelymonitoredinpatientsreceivingaliskiren.Aliskiren;Valsartan:(Moderate)Aliskirencanenhancetheeffectsofvasodilatorsonbloodpressureifgivenconcomitantly.Thisadditiveeffectmaybedesirable,butdosagesmustbeadjustedaccordingly.Bloodpressureandelectrolytesshouldberoutinelymonitoredinpatientsreceivingaliskiren.Alosetron:(Minor)AlosetronmayinhibitthemetabolismofdrugsmetabolizedbyN-acetyltransferase,suchashydralazine,however,thisinteractionhasnotbeenstudied.Alprostadil:(Minor)Theconcomitantuseofsystemicalprostadilinjectionandantihypertensiveagents,suchasthevasodilators,maycauseadditivehypotension.Cautionisadvisedwiththiscombination.Systemicdruginteractionswiththeurethralsuppository(MUSE)oralprostadilintracavernousinjectionareunlikelyinmostpatientsbecauseloworundetectableamountsofthedrugarefoundintheperipheralvenouscirculationfollowingadministration.Inthosemenwithsignificantcorporacavernosavenousleakage,hypotensionmightbemorelikely.Usecautionwithin-clinicdosingforerectiledysfunction(ED)andmonitorfortheeffectsonbloodpressure.Inaddition,thepresenceofmedicationsinthecirculationthatattenuateerectilefunctionmayinfluencetheresponsetoalprostadil.However,inclinicaltrialswithalprostadilintracavernousinjection,anti-hypertensiveagentshadnoapparenteffectonthesafetyandefficacyofalprostadil.Amifostine:(Major)Patientsreceivingantihypertensiveagentsshouldbecloselymonitoredduringamifostineinfusionsduetoadditiveeffects.Ifpossible,patientsshouldnottaketheirantihypertensivemedication24hoursbeforereceivingamifostine.Patientswhocannotstoptheirantihypertensiveagentsshouldnotreceiveamifostineorbecloselymonitoredduringtheinfusionand,possibly,givenlowerdoses.Amobarbital:(Moderate)Concurrentuseofamobarbitalwithantihypertensiveagentsmayleadtohypotension.Monitorfordecreasesinbloodpressureduringtimesofcoadministration.Amphetamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Amphetamine;Dextroamphetamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.AmylNitrite:(Moderate)Concomitantuseofnitrateswithantihypertensivescancauseadditivehypotensiveeffects.Dosageadjustmentsmaybenecessary.Astudyof28patientswithheartfailureindicatedthatconcomitantadministrationoforalhydralazinepreventedthedevelopmentoftolerancetocontinuousnitroglycerininfusions.Apomorphine:(Moderate)Concurrentuseofapomorphineandvasodilatorscancausegreaterdecreasesinbloodpressurethanuseofapomorphinealone.Patientsreceivingacombinationofapomorphineandvasodilatorsshouldbecloselymonitoredforhypotensionandorthostasis.Apraclonidine:(Minor)Alphablockersasaclassmayreduceheartrateandbloodpressure.Whilenospecificdruginteractionshavebeenidentifiedwithsystemicagentsandapraclonidineduringclinicaltrials,itistheoreticallypossiblethatadditivebloodpressurereductionscouldoccurwhenapraclonidineiscombinedwiththeuseofantihypertensiveagents.Patientsusingcardiovasculardrugsconcomitantlywithapraclonidineshouldhavetheirpulseandbloodpressuremonitoredperiodically.Aripiprazole:(Minor)Aripiprazolemayenhancethehypotensiveeffectsofantihypertensiveagents.Articaine;Epinephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Asenapine:(Moderate)Secondarytoalpha-blockade,asenapinecanproducevasodilationthatmayresultinadditiveeffectsduringconcurrentuseofantihypertensiveagents.Thepotentialreductioninbloodpressurecanprecipitateorthostatichypotensionandassociateddizziness,tachycardia,andsyncope.Ifconcurrentuseofasenapineandantihypertensiveagentsisnecessary,patientsshouldbecounseledonmeasurestopreventorthostatichypotension,suchassittingontheedgeofthebedforseveralminutespriortostandinginthemorningandrisingslowlyfromaseatedposition.Closemonitoringofbloodpressureisrecommendeduntilthefulleffectsofthecombinationtherapyareknown.Baclofen:(Moderate)Baclofenhasbeenassociatedwithhypotension.Concurrentusewithbaclofenandantihypertensiveagentsmayresultinadditivehypotension.Dosageadjustmentsoftheantihypertensivemedicationmayberequired.BelladonnaAlkaloids;Ergotamine;Phenobarbital:(Minor)Useofvasodilatorsandergotalkaloidsmayresultinantagonismofthevasoconstrictiveeffectsoftheergotderivative.Thisinteractionisusedtoclinicalbenefit,i.e.,nitroprussideusedforsupportivecareofergotalkaloidtoxicity.Benzphetamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Bortezomib:(Moderate)Patientsonantihypertensiveagentsreceivingbortezomibtreatmentmayrequireclosemonitoringoftheirbloodpressureanddosageadjustmentoftheirmedication.Duringclinicaltrialsofbortezomib,hypotension(includingorthostatichypotension)wasreportedinroughly12percentofpatients;mosteventsweremildtomoderateinseverity,withmoredramatichypotensionreportedin4percentofdrugrecipients.Additionally,bortezomibandhydralazinecanbothcauseperipheralneuropathy;coadministerthesedrugscautiously,astheriskofperipheralneuropathymaybeadditive.Brompheniramine;Carbetapentane;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Brompheniramine;Dextromethorphan;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Brompheniramine;Hydrocodone;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Brompheniramine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Brompheniramine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Brompheniramine;Pseudoephedrine;Dextromethorphan:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Bupivacaine;Epinephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Cabergoline:(Moderate)Cabergolineshouldbeusedcautiouslywithantihypertensiveagents,includinghydralazine.Cabergolinehasbeenassociatedwithhypotension.Initialdosesofcabergolinehigherthan1mgmayproduceorthostatichypotension.Itmaybeadvisabletomonitorbloodpressure.Carbetapentane;Chlorpheniramine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbetapentane;Diphenhydramine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbetapentane;Guaifenesin;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbetapentane;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbetapentane;Phenylephrine;Pyrilamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbetapentane;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbidopa;Levodopa:(Moderate)Concomitantuseofantihypertensiveagentswithlevodopacanresultinadditivehypotensiveeffects.Carbidopa;Levodopa;Entacapone:(Moderate)Concomitantuseofantihypertensiveagentswithlevodopacanresultinadditivehypotensiveeffects.Carbinoxamine;Dextromethorphan;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbinoxamine;Hydrocodone;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbinoxamine;Hydrocodone;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbinoxamine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Carbinoxamine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Cariprazine:(Moderate)Orthostaticvitalsignsshouldbemonitoredinpatientswhoareatriskforhypotension,suchasthosereceivingcariprazineincombinationwithantihypertensiveagents.Atypicalantipsychoticsmaycauseorthostatichypotensionandsyncope,mostcommonlyduringtreatmentinitiationanddosageincreases.Patientsshouldbeinformedaboutmeasurestopreventorthostatichypotension,suchassittingontheedgeofthebedforseveralminutespriortostandinginthemorning,orrisingslowlyfromaseatedposition.Consideracariprazinedosereductionifhypotensionoccurs.Cetirizine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlophedianol;Dexchlorpheniramine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlophedianol;Guaifenesin;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chloroprocaine:(Moderate)Localanestheticsmaycauseadditivehypotensionincombinationwithantihypertensiveagents.Chlorpheniramine;Dextromethorphan;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlorpheniramine;Dextromethorphan;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlorpheniramine;Dihydrocodeine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlorpheniramine;Dihydrocodeine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlorpheniramine;Guaifenesin;Hydrocodone;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlorpheniramine;Hydrocodone;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlorpheniramine;Hydrocodone;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlorpheniramine;Ibuprofen;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlorpheniramine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Chlorpheniramine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Clozapine:(Moderate)Clozapineusedconcomitantlywiththeantihypertensiveagentscanincreasetheriskandseverityofhypotensionbypotentiatingtheeffectoftheantihypertensivedrug.Cocaine:(Major)Useofcocainewithantihypertensiveagentsmayincreasetheantihypertensiveeffectsoftheantihypertensivemedicationsormaypotentiatecocaine-inducedsympatheticstimulation.Codeine;Guaifenesin;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Codeine;Phenylephrine;Promethazine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Co-EnzymeQ10,Ubiquinone:(Moderate)Co-enzymeQ10,ubiquinone(CoQ10)maylowerbloodpressure.CoQ10useincombinationwithantihypertensiveagentsmayleadtoadditionalreductionsinbloodpressureinsomeindividuals.PatientswhochoosetotakeCoQ10concurrentlywithantihypertensivemedicationsshouldreceiveperiodicbloodpressuremonitoring.PatientsshouldbeadvisedtoinformtheirprescriberoftheiruseofCoQ10.ConjugatedEstrogens:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.ConjugatedEstrogens;Bazedoxifene:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.ConjugatedEstrogens;Medroxyprogesterone:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Desloratadine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Desogestrel;EthinylEstradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Dexbrompheniramine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dexchlorpheniramine;Dextromethorphan;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dexmedetomidine:(Moderate)Concomitantadministrationofdexmedetomidineandvasodilatorscouldleadtoadditivehypotensionandbradycardia;usetogetherwithcaution.Inclinicaltrialswherevasodilatorswereco-administeredwithdexmedetomidineanadditivepharmacodynamiceffectwasnotobserved.However,bothvasodilatorsanddexmeditomidinemaycausesymptomatichypotension.Ifhypotensionoccurs,dosereductionofoneorbothdrugsmaybeneededandsupportivemeasuresinstituted.Dexmethylphenidate:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dextroamphetamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dextromethorphan;Diphenhydramine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dextromethorphan;Guaifenesin;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dextromethorphan;Guaifenesin;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dextromethorphan;Quinidine:(Moderate)Quinidinecandecreasebloodpressureandshouldbeusedcautiouslyinpatientsreceivingantihypertensiveagentsduetothepotentialforadditivehypotension.Diazoxide:(Moderate)Hypotensionandbradycardiahavebeenreportedwhendiazoxideandhydralazinewereadministeredtogether.ThemanufactureradvisesthatIVdiazoxideshouldnotbeadministeredtopatientswithin6hoursofreceivinghydralazine.Dienogest;Estradiolvalerate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Diethylpropion:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Diethylstilbestrol,DES:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Dihydrocodeine;Guaifenesin;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dihydroergotamine:(Minor)Thecombineduseofvasodilatorsandtheergotalkaloidswilllikelyresultinantagonismofthevasoconstrictiveeffectsoftheergotderivative.Clinically,forexample,vasodilatorsmaybeusedforsupportivecareofergotalkaloidtoxicity;withprecautionstoavoidhypotension.Diphenhydramine;Hydrocodone;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Diphenhydramine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dobutamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Dopamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Doxapram:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Drospirenone;Estetrol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Drospirenone;Estradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Drospirenone;EthinylEstradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Drospirenone;EthinylEstradiol;Levomefolate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Duloxetine:(Moderate)Orthostatichypotensionandsyncopehavebeenreportedduringduloxetineadministration.Theconcurrentadministrationofantihypertensiveagentsandduloxetinemayincreasetheriskofhypotension.Monitorbloodpressureifthecombinationisnecessary.Elagolix;Estradiol;Norethindroneacetate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Enflurane:(Moderate)Generalanestheticscanpotentiatethehypotensiveeffectsofantihypertensiveagents.Ephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Ephedrine;Guaifenesin:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Epinephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Epoprostenol:(Major)Furtherreductionsinbloodpressuremayoccurwhenvasodilatorsarecombinedwithepoprostenol.Ergonovine:(Minor)Thecombineduseofvasodilatorsandergotalkaloidsmayresultinantagonismofthevasoconstrictiveeffectsoftheergotderivative.Thisinteractionisusedtoclinicalbenefit,i.e.,nitroprussideusedforsupportivecareofergotalkaloidtoxicity.Ergotamine:(Minor)Useofvasodilatorsandergotalkaloidsmayresultinantagonismofthevasoconstrictiveeffectsoftheergotderivative.Thisinteractionisusedtoclinicalbenefit,i.e.,nitroprussideusedforsupportivecareofergotalkaloidtoxicity.Ergotamine;Caffeine:(Minor)Useofvasodilatorsandergotalkaloidsmayresultinantagonismofthevasoconstrictiveeffectsoftheergotderivative.Thisinteractionisusedtoclinicalbenefit,i.e.,nitroprussideusedforsupportivecareofergotalkaloidtoxicity.EsterifiedEstrogens:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.EsterifiedEstrogens;Methyltestosterone:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.EstradiolCypionate;Medroxyprogesterone:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Estradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Estradiol;Levonorgestrel:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Estradiol;Norethindrone:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Estradiol;Norgestimate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Estradiol;Progesterone:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Estrogens:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Estropipate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.EthinylEstradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.EthinylEstradiol;Levonorgestrel;FolicAcid;Levomefolate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.EthinylEstradiol;Norelgestromin:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.EthinylEstradiol;NorethindroneAcetate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.EthinylEstradiol;Norgestrel:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.EthynodiolDiacetate;EthinylEstradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Etomidate:(Moderate)Generalanestheticscanpotentiatethehypotensiveeffectsofantihypertensiveagents.Etonogestrel;EthinylEstradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Fexofenadine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.FishOil,Omega-3FattyAcids(DietarySupplements):(Moderate)Highdosesoffishoilsupplementsmayproduceabloodpressureloweringeffect.Itispossiblethatadditivereductionsinbloodpressuremaybeseenwhenfishoilsareusedinapatientalreadytakingantihypertensiveagents.Fospropofol:(Moderate)Generalanestheticscanpotentiatethehypotensiveeffectsofantihypertensiveagents.Generalanesthetics:(Moderate)Generalanestheticscanpotentiatethehypotensiveeffectsofantihypertensiveagents.Guaifenesin;Hydrocodone;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Guaifenesin;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Guaifenesin;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Haloperidol:(Moderate)Ingeneral,haloperidolshouldbeusedcautiouslywithantihypertensiveagentsduetothepossibilityofadditivehypotension.Halothane:(Moderate)Generalanestheticscanpotentiatethehypotensiveeffectsofantihypertensiveagents.Hydralazine;IsosorbideDinitrate,ISDN:(Moderate)Concomitantuseofnitrateswithantihypertensivescancauseadditivehypotensiveeffects.Dosageadjustmentsmaybenecessary.Astudyof28patientswithheartfailureindicatedthatconcomitantadministrationoforalhydralazinepreventedthedevelopmentoftolerancetocontinuousnitroglycerininfusions.Hydrocodone;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Hydrocodone;PotassiumGuaiacolsulfonate;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Hydrocodone;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Hyoscyamine;Methenamine;MethyleneBlue;PhenylSalicylate;SodiumBiphosphate:(Moderate)Usesodiumphosphatescautiouslywithhydralazineasconcurrentusecancausehypernatremia.IbritumomabTiuxetan:(Moderate)Usesodiumphosphatescautiouslywithhydralazineasconcurrentusecancausehypernatremia.Ibuprofen;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Iloperidone:(Moderate)Secondarytoalpha-blockade,iloperidonecanproducevasodilationthatmayresultinadditiveeffectsduringconcurrentusewithantihypertensiveagents.Thepotentialreductioninbloodpressurecanprecipitateorthostatichypotensionandassociateddizziness,tachycardia,andsyncope.Ifconcurrentuseofiloperidoneandantihypertensiveagentsisnecessary,patientsshouldbecounseledonmeasurestopreventorthostatichypotension,suchassittingontheedgeofthebedforseveralminutespriortostandinginthemorningandrisingslowlyfromaseatedposition.Closemonitoringofbloodpressureisrecommendeduntilthefulleffectsofthecombinationtherapyareknown.Iloprost:(Moderate)Vasodilatorsmayhaveadditivehypotensiveeffectswhengivenwithotherantihypertensiveagents.IntravenousLipidEmulsions:(Moderate)Highdosesoffishoilsupplementsmayproduceabloodpressureloweringeffect.Itispossiblethatadditivereductionsinbloodpressuremaybeseenwhenfishoilsareusedinapatientalreadytakingantihypertensiveagents.Isocarboxazid:(Moderate)Monoamineoxidaseinhibitors(MAOIs)potentiatetheconcentrationofcatecholaminesintheCNS.Theseeffectscanbeadditivewiththoseofhydralazine,socautionshouldbeusedwhenadministeringthesedrugstogether.RasagilineisaselectiveMAO-Binhibitoratmanufacturerrecommendeddoses;therefore,aseriousinteractionwithhydralazineisexpectedtobelesslikelytooccurwithrasagiline.Isoflurane:(Moderate)Generalanestheticscanpotentiatethehypotensiveeffectsofantihypertensiveagents.Isoproterenol:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.IsosorbideDinitrate,ISDN:(Moderate)Concomitantuseofnitrateswithantihypertensivescancauseadditivehypotensiveeffects.Dosageadjustmentsmaybenecessary.Astudyof28patientswithheartfailureindicatedthatconcomitantadministrationoforalhydralazinepreventedthedevelopmentoftolerancetocontinuousnitroglycerininfusions.IsosorbideMononitrate:(Moderate)Concomitantuseofnitrateswithantihypertensivescancauseadditivehypotensiveeffects.Dosageadjustmentsmaybenecessary.Astudyof28patientswithheartfailureindicatedthatconcomitantadministrationoforalhydralazinepreventedthedevelopmentoftolerancetocontinuousnitroglycerininfusions.Ketamine:(Moderate)Generalanestheticscanpotentiatethehypotensiveeffectsofantihypertensiveagents.Levodopa:(Moderate)Concomitantuseofantihypertensiveagentswithlevodopacanresultinadditivehypotensiveeffects.Levonorgestrel;EthinylEstradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Levonorgestrel;EthinylEstradiol;FerrousBisglycinate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Lidocaine;Epinephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Lisdexamfetamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Lofexidine:(Major)Becausethecentralalpha-2agonisteffectsoflofexidinecancausehypotensionandorthostasis,thedrugshouldbeavoided,ifpossible,incombinationwithothermedicationsthatcandecreasebloodpressuresuchassystemicvasodilators.Ifcoadministrationisrequired,bloodpressureshouldbemonitored,particularlyafterdosechangesofeitheragent.Adjustmentsshouldbemadeasclinicallyindicated.Loratadine;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Lovastatin;Niacin:(Moderate)Cutaneousvasodilationinducedbyniacinmaybecomeproblematicifhigh-doseniacinisusedconcomitantlywithotherantihypertensiveagents,especiallyperipheralvasodilators.Thiseffectisofparticularconcerninthesettingofacutemyocardialinfarction,unstableangina,orotheracutehemodynamiccompromise.Theinteractionisharmlessunlessniacinaugmentsthehypotensiveactionsofclonidine.Lurasidone:(Moderate)Duetotheantagonismoflurasidoneatalpha-1adrenergicreceptors,thedrugmayenhancethehypotensiveeffectsofalpha-blockersandotherantihypertensiveagents.Ifconcurrentuseoflurasidoneandantihypertensiveagentsisnecessary,patientsshouldbecounseledonmeasurestopreventorthostatichypotension,suchassittingontheedgeofthebedforseveralminutespriortostandinginthemorningandrisingslowlyfromaseatedposition.Closemonitoringofbloodpressureisrecommendeduntilthefulleffectsofthecombinationtherapyareknown.Mepivacaine;Levonordefrin:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Mesoridazine:(Moderate)Antihypertensivesthatcanexacerbatethehypotensiveeffectsofmesoridazineincludehydralazine.Patientsshouldbemonitoredformaintenanceofappropriateclinicalresponsetoantihypertensivetherapyifaphenothiazineisadded;thesecombinationsshouldbeavoidedwheneverpossible.Mestranol;Norethindrone:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Methamphetamine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Methenamine;SodiumAcidPhosphate:(Moderate)Usesodiumphosphatescautiouslywithhydralazineasconcurrentusecancausehypernatremia.Methenamine;SodiumAcidPhosphate;MethyleneBlue;Hyoscyamine:(Moderate)Usesodiumphosphatescautiouslywithhydralazineasconcurrentusecancausehypernatremia.Methohexital:(Moderate)Concurrentuseofmethohexitalandantihypertensiveagentsincreasestheriskofdevelopinghypotension.Methylphenidate:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Midodrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Milrinone:(Moderate)Concurrentadministrationofantihypertensiveagentscouldleadtoadditivehypotensionwhenadministeredwithmilrinone.Titratemilrinonedosageaccordingtohemodynamicresponse.Naproxen;Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Nesiritide,BNP:(Moderate)Thepotentialforhypotensionmaybeincreasedwhencoadministeringnesiritidewithvasodilators.Reducethedoseofordiscontinuenesiritideinpatientswhodevelophypotension.Inclinicaltrials,nodruginteractionsweredetectedexceptforanincreaseinsymptomatichypotensioninpatientsreceivingafterloadreducers,suchasvasodilators.Niacin,Niacinamide:(Moderate)Cutaneousvasodilationinducedbyniacinmaybecomeproblematicifhigh-doseniacinisusedconcomitantlywithotherantihypertensiveagents,especiallyperipheralvasodilators.Thiseffectisofparticularconcerninthesettingofacutemyocardialinfarction,unstableangina,orotheracutehemodynamiccompromise.Theinteractionisharmlessunlessniacinaugmentsthehypotensiveactionsofclonidine.Niacin;Simvastatin:(Moderate)Cutaneousvasodilationinducedbyniacinmaybecomeproblematicifhigh-doseniacinisusedconcomitantlywithotherantihypertensiveagents,especiallyperipheralvasodilators.Thiseffectisofparticularconcerninthesettingofacutemyocardialinfarction,unstableangina,orotheracutehemodynamiccompromise.Theinteractionisharmlessunlessniacinaugmentsthehypotensiveactionsofclonidine.Nitrates:(Moderate)Concomitantuseofnitrateswithantihypertensivescancauseadditivehypotensiveeffects.Dosageadjustmentsmaybenecessary.Astudyof28patientswithheartfailureindicatedthatconcomitantadministrationoforalhydralazinepreventedthedevelopmentoftolerancetocontinuousnitroglycerininfusions.Nitroglycerin:(Moderate)Concomitantuseofnitrateswithantihypertensivescancauseadditivehypotensiveeffects.Dosageadjustmentsmaybenecessary.Astudyof28patientswithheartfailureindicatedthatconcomitantadministrationoforalhydralazinepreventedthedevelopmentoftolerancetocontinuousnitroglycerininfusions.Nonsteroidalantiinflammatorydrugs:(Moderate)Ifnonsteroidalanti-inflammatorydrugs(NSAIDs)andanantihypertensivedrugareconcurrentlyused,carefullymonitorthepatientforsignsandsymptomsofrenalinsufficiencyandbloodpressurecontrol.DosesofantihypertensivemedicationsmayrequireadjustmentinpatientsreceivingconcurrentNSAIDs.NSAIDs,tovaryingdegrees,havebeenassociatedwithanelevationinbloodpressure.Thiseffectismostsignificantinpatientsreceivingconcurrentantihypertensiveagentsandlong-termNSAIDtherapy.NSAIDscauseadose-dependentreductioninprostaglandinformation,whichmayresultinareductioninrenalbloodflowleadingtorenalinsufficiencyandanincreaseinbloodpressurethatareoftenaccompaniedbyperipheraledemaandweightgain.PatientswhorelyuponrenalprostaglandinstomaintainrenalperfusionmayhaveacuterenalbloodflowreductionwithNSAIDusage.Elderlypatientsmaybeatincreasedriskofadverseeffectsfromcombinedlong-termNSAIDtherapyandantihypertensiveagents,especiallydiuretics,duetoage-relateddecreasesinrenalfunctionandanincreasedriskofstrokeandcoronaryarterydisease.Norepinephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.NorethindroneAcetate;EthinylEstradiol;Ferrousfumarate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Norethindrone;EthinylEstradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Norethindrone;EthinylEstradiol;Ferrousfumarate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Norgestimate;EthinylEstradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Olanzapine:(Moderate)Olanzapinemayinduceorthostatichypotensionandthusenhancetheeffectsofantihypertensiveagents.Olanzapine;Fluoxetine:(Moderate)Olanzapinemayinduceorthostatichypotensionandthusenhancetheeffectsofantihypertensiveagents.Olanzapine;Samidorphan:(Moderate)Olanzapinemayinduceorthostatichypotensionandthusenhancetheeffectsofantihypertensiveagents.Oxymetazoline:(Major)Thevasoconstrictingactionsofoxymetazoline,analphaadrenergicagonist,mayreducetheantihypertensiveeffectsproducedbyvasodilators.Alsovasodilatorscanantagonizetheeffectivenessofoxymetazoline.Ifthesedrugsareusedtogether,closelymonitorforchangesinbloodpressure.Paliperidone:(Moderate)Paliperidonemaycauseorthostatichypotension,therebyenhancingthehypotensiveeffectsofantihypertensiveagents.Orthostaticvitalsignsshouldbemonitoredinpatientsreceivingpaliperidoneandhydralazinewhoaresusceptibletohypotension.Pemoline:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Pentoxifylline:(Moderate)Pentoxifyllinehasbeenusedconcurrentlywithantihypertensivedrugs(betablockers,diuretics)withoutobservedproblems.Smalldecreasesinbloodpressurehavebeenobservedinsomepatientstreatedwithpentoxifylline;periodicsystemicbloodpressuremonitoringisrecommendedforpatientsreceivingconcomitantantihypertensives.Ifindicated,dosageoftheantihypertensiveagentsshouldbereduced.Pexidartinib:(Moderate)Monitorforevidenceofhepatotoxicityifpexidartinibiscoadministeredwithhydralazine.Avoidconcurrentuseinpatientswithincreasedserumtransaminases,totalbilirubin,ordirectbilirubin(morethanULN)oractiveliverorbiliarytractdisease.Phendimetrazine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Phenelzine:(Moderate)Additivehypotensiveeffectsmaybeseenwhenphenelzine,aMAOI,iscombinedwithhydralazine,apotentvasodilator.Inaddition,hydralazinemaycausepronouncedtachycardiawhencombinedwithMAOIs.CarefulmonitoringofbloodpressureissuggestedduringconcurrenttherapyofMAOIswithvasodilators.Patientsshouldbeinstructedtoriseslowlyfromasittingposition,andtoreportsyncopeorchangesinbloodpressureorheartratetotheirhealthcareproviderduringconcurrentuseofphenelzineandanantihypertensiveagent.Phentermine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Phentermine;Topiramate:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.PotassiumPhosphate;SodiumPhosphate:(Moderate)Usesodiumphosphatescautiouslywithhydralazineasconcurrentusecancausehypernatremia.Prazosin:(Moderate)Prazosiniswell-knowntoproducea'first-dose'phenomenon.Somepatientsdevelopsignificanthypotensionshortlyafteradministrationofthefirstdose.Thefirstdoseresponse(acuteposturalhypotension)ofprazosinmaybeexaggeratedinpatientswhoarereceivingbeta-adrenergicblockers,diuretics,orotherantihypertensiveagents.Concomitantadministrationofprazosinwithotherantihypertensiveagentsisnotprohibited,however.Thiscanbetherapeuticallyadvantageous,butlowerdosagesofeachagentshouldbeused.Prilocaine;Epinephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Procainamide:(Moderate)Procainamidecandecreasebloodpressureandshouldbeusedcautiouslyinpatientsreceivingantihypertensiveagents.Intravenousadministrationofprocainamideismorelikelytocausehypotensiveeffects.Procaine:(Moderate)Localanestheticsmaycauseadditivehypotensionincombinationwithantihypertensiveagents.Promethazine;Phenylephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Propofol:(Moderate)Generalanestheticscanpotentiatethehypotensiveeffectsofantihypertensiveagents.Pseudoephedrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Pseudoephedrine;Triprolidine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Quinidine:(Moderate)Quinidinecandecreasebloodpressureandshouldbeusedcautiouslyinpatientsreceivingantihypertensiveagentsduetothepotentialforadditivehypotension.Racepinephrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Rasagiline:(Moderate)Monoamineoxidaseinhibitors(MAOIs)potentiatetheconcentrationofcatecholaminesintheCNS.Theseeffectscanbeadditivewiththoseofhydralazine,socautionshouldbeusedwhenadministeringthesedrugstogether.RasagilineisaselectiveMAO-Binhibitoratmanufacturerrecommendeddoses;therefore,aseriousinteractionwithhydralazineisexpectedtobelesslikelytooccurwithrasagiline.Relugolix;Estradiol;Norethindroneacetate:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Riluzole:(Moderate)Monitorforsignsandsymptomsofhepaticinjuryduringcoadministrationofriluzoleandhydralazine.Concomitantusemayincreasetheriskforhepatotoxicity.Discontinueriluzoleifclinicalsignsofliverdysfunctionarepresent.Risperidone:(Moderate)Risperidonemayinduceorthostatichypotensionandthusenhancethehypotensiveeffectsofantihypertensiveagents.Lowerinitialdosesorslowerdosetitrationofrisperidonemaybenecessaryinpatientsreceivingantihypertensiveagentsconcomitantly.Ritodrine:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.SegesteroneAcetate;EthinylEstradiol:(Minor)Theadministrationofestrogenscanincreasefluidretention,whichincreasesbloodpressure,therebyantagonizingtheantihypertensiveeffectsofhydralazine.Serdexmethylphenidate;Dexmethylphenidate:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Sevoflurane:(Moderate)Generalanestheticscanpotentiatethehypotensiveeffectsofantihypertensiveagents.Silodosin:(Moderate)Duringclinicaltrialswithsilodosin,theincidenceofdizzinessandorthostatichypotensionwashigherinpatientsreceivingconcomitantantihypertensivetreatment.Thus,cautionisadvisablewhensilodosinisadministeredwithantihypertensiveagents.SodiumPhosphateMonobasicMonohydrate;SodiumPhosphateDibasicAnhydrous:(Moderate)Usesodiumphosphatescautiouslywithhydralazineasconcurrentusecancausehypernatremia.Sympathomimetics:(Moderate)Usesympathomimeticagentswithcautioninpatientsreceivingtherapyforhypertension.Patientsshouldbemonitoredtoconfirmthatthedesiredantihypertensiveeffectisachieved.Sympathomimeticscanincreasebloodpressureandheartrate,andantagonizetheantihypertensiveeffectsofvasodilatorswhenadministeredconcomitantly.Anginalpainmaybeinducedwhencoronaryinsufficiencyispresent.Tetracaine:(Moderate)Localanestheticsmaycauseadditivehypotensionincombinationwithantihypertensiveagents.Useextremecautionwiththeconcomitantuseoftetracaineandantihypertensiveagents.Thiopental:(Moderate)Additivehypotensiveeffectsmayoccurwhenvasodilatorsareusedconcomitantlywiththiopental.Dosagesshouldbeadjustedcarefully,accordingtobloodpressure.Thiothixene:(Moderate)Thiothixeneshouldbeusedcautiouslyinpatientsreceivingantihypertensiveagents.Additivehypotensiveeffectsarepossible.Tizanidine:(Moderate)Concurrentuseoftizanidinewithantihypertensiveagentscanresultinsignificanthypotension.Cautionisadvisedwhentizanidineistobeusedinpatientsreceivingconcurrentantihypertensivetherapy.Tranylcypromine:(Major)Avoidconcomitantuseofvasodilatorsandtranylcypromineduetotheriskofadditivehypotension.Potentialforthisinteractionpersistsforupto10daysafterdiscontinuationoftranylcypromine(or4to5half-livesafterdiscontinuationofthevasodilator).Ifamedication-freeintervalisnotfeasible,initiatetherapyatthelowestappropriatedoseandmonitorbloodpressureclosely.Trazodone:(Minor)Duetoadditivehypotensiveeffects,patientsreceivingantihypertensiveagentsconcurrentlywithtrazodonemayhaveexcessivehypotension.Decreaseddosageoftheantihypertensiveagentmayberequiredwhengivenwithtrazodone.VincristineLiposomal:(Moderate)Usesodiumphosphatescautiouslywithhydralazineasconcurrentusecancausehypernatremia.Yohimbine:(Moderate)Yohimbinecanincreasebloodpressureandthereforecanantagonizethetherapeuticactionofantihypertensiveagents.UsewithparticularcautioninhypertensivepatientswithhighoruncontrolledBP.Zalcitabine,ddC:(Major)Coadministrationofzalcitabine,ddCwithdrugsassociatedwithperipheralneuropathy,suchashydralazine,shouldbeavoidedwhenpossible.Ziprasidone:(Minor)Ziprasidoneisamoderateantagonistofalpha-1receptorsandmaycauseorthostatichypotensionwithorwithouttachycardia,dizziness,orsyncope.Additivehypotensiveeffectsarepossibleifziprasidoneisusedconcurrentlywithantihypertensiveagents. PREGNANCYANDLACTATION PregnancyTherearenoadequateandwell-controlledstudiesinpregnantwomen.Althoughclinicalexperiencedoesnotidentifyevidenceoffetaladverseeffects,usehydralazineduringpregnancyonlyiftheexpectedbenefitoutweighsthepotentialrisktothefetus.Intravenoushydralazineiscommonlyusedforacute-onsetseverehypertensioninpregnancy.Animalstudiesindicatethathydralazineisteratogenicinmiceat20to30timesthemaximumdailydoseof200to300mgandpossiblyinrabbitsat10to15timesthemaximumdailyhumandose,butthatitisnonteratogenicinrats.Teratogeniceffectsobservedwerecleftpalateandmalformationsoffacialandcranialbones.Usecautionwhenadministeringhydralazinetoabreast-feedingwoman.PreviousAmericanAcademyofPediatrics(AAP)recommendationsconsideredhydralazinetobegenerallycompatiblewithbreast-feeding.Hydralazineisdistributedintohumanmilk.Inacasereportofamothertakinghydralazine50mgPO3timesdaily,hydralazinebreastmilkconcentrationswere130mcg/Lat0.5and2hoursafteradose.Basedontheseconcentrations,itisestimatedthatanursinginfantwouldreceive13mcgofhydralazineper75mLofbreastmilk. MECHANISMOFACTION Hydralazineisaperipheralvasodilator;itcausesrelaxationofarteriolarsmoothmuscleviaadirecteffect.Althoughstimulationofthesympatheticnervoussystemisassociatedwithhydralazineadministration,thisisacompensatoryresponseandnotacomponentofitsmechanism.Themolecularexplanationofhydralazine'smechanismisnotfullyunderstood;however,similartoorganicnitratesandnitroprusside,itisthoughtthathydralazineinterfereswiththecalciummovementswithinvascularsmoothmusclethatareresponsibleforinitiatingandmaintainingthecontractilestate.Incontrasttoorganicnitratesandsodiumnitroprusside,however,hydralazineisselectiveforarterioles.Theperipheralvasodilatingeffectsofhydralazineresultindecreasedarterialbloodpressure(diastolicmorethansystolic)andperipheralvascularresistance.Inaddition,thehydralazine-inducedreflexautonomicresponseincreasesheartrate,strokevolume,cardiacoutput,andleftventricularejectionfraction.Thepreferentialdilationofarterioles,ascomparedtoveins,minimizesposturalhypotensionandpromotestheincreaseincardiacoutputeventhoughthehypotensiveeffectsofhydralazinearediminishedsomewhatbythisincreaseincardiacoutput.Thereisalsoevidencesuggestinghydralazineexertsapositiveinotropiceffectonthefailinghumanventricle. Animalandlimitedhumandataindicatethatnitricoxide(NO)maybegeneratedfromhydralazinethatalsohasanantioxidantqualitytoenhancetheeffectsofnitratesandtomitigatethetoleranceassociatedwithchronicnitratetherapy.Theantioxidanteffectofhydralazinecanbeattributedtoitsabilityininhibitingoxidaseformation.TheaccumulationofoxidativefreeradicalscreatesanenvironmentwherechronicreductionsinNObioavailabilitycontributetoalossofskeletalmusclemicrovessels.Thiseffect,inturn,leadstoimpairedmuscleperfusionwithelevatedmetabolicdemand.StudiesshowthattreatmentwithhydralazinemarkedlyinhibitsoxidasewhichplaysaroleinregulatingthebioactivityofNO,producedeitherendogenouslyorwhenadministeredexogenously. Cerebral,coronary,splanchnic,andrenalbloodflowusuallyincreasefollowingadministrationofhydralazine,whileurinaryparametersaregenerallyunaffected.Hydralazineincreasesreninactivityinplasma,presumablybytherenaljuxtaglomerularcellsinresponsetosympatheticnervoussystemstimulation;theincreaseinreninactivityleadstotheproductionofangiotensinII,whichstimulatesaldosteroneandthus,sodiumreabsorption.Duetofluidretention,plasmavolumeincreases.Asaresult,tolerancecandevelop,whichmayaccountfortheabsenceofimprovementinsomepatientsreceivingthedrugforprolongedperiodsoftime. Asanantihypertensive,hydralazinedoesnotleadtoimprovementsinLVH.HydralazinemayactuallyworsenLVH,potentiallyduetoreflextachycardiaandsympatheticstimulation,whichmaycounteractthebenefitsofafterloadreduction. PHARMACOKINETICS Hydralazineisadministeredorallyandparenterally.Hydralazinedistributesthroughoutthebodytissuesandhasaparticularlyhighaffinityforarterialwalls.Thedrugcrossestheplacentaanddistributesinbreastmilk,butnottoaclinicallysignificantdegree.Plasmaproteinbindingisabout87%.Hydralazineisextensivelyhepaticallymetabolizedandplasmalevelscanvaryduetopolymorphicacetylation.Boththeunchangeddrug(25%)anditsmetabolitesareexcretedintheurineandfeces.Thehalf-lifeofthedruginanormalpatientis3—7hours.OralRouteAlthoughhydralazineisapproximately90%absorbedfollowingoraladministration,systemicbioavailabilityisconsiderablylowerafteroralversusintramuscularorintravenousadministrationduetoextensivefirst-passmetabolism.Oralbioavailabilityisalsodependentontheacetylationphenotypeofthepatient,anditisapproximately50%in'slow'acetylatorsand30%in'fast'acetylators.Althoughfoodinthegutenhancesabsorptionofhydralazine,food-relatedreductionsinhydralazinebloodlevelshavebeenassociatedwithreducedantihypertensiveeffects,possiblyduetoanincreaseinintravascularconversionofthedrugtohydralazinepyruvicacidhydrazone.Forthisreason,ithasbeensuggestedthatpatientstakethismedicationatafixedtimeinrelationshiptomeals.Peakhydralazineplasmaconcentrationisreachedin1—2hours.Hypotensiveeffectsoccur20—30minutesfollowinganoraldose.Theantihypertensiveeffectsofanoralhydralazinedoselastabout2—4hours.IntravenousRouteHypotensiveeffectsoccur5—30minutesafteranIVdose.TheantihypertensiveeffectsofanIVdoselast2—6hoursonaverage,althoughtheeffectsofaparenteraldosecanlastupto12hours;theaffinityofhydralazineforarterialwallsmaypartiallyexplaintheprolongedeffect.IntramuscularRouteHypotensiveeffectsoccur10—30minutesafteranIMdose.TheantihypertensiveeffectsofanIMdoselast2—6hoursonaverage,althoughtheeffectsofaparenteraldosecanlastupto12hourspossiblyduetotheaffinityofhydralazineforarterialwalls. 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