How long can you go without blood pressure medication

MEAL PLAN

Get the details of a healthy lifestyle plan so powerful that many people can wipe out the need for high blood pressure medication in as little as three days.

Scott H hated being on medications. The 59-year-old electrical engineer from Los Angeles was taking three different pills to lower his blood pressure.

They worked, somewhat. His blood pressure was 130/85, lower than his pre-medication numbers, but still not low enough.

130 Is the New “High”

In recently published guidelines, the American Heart Association, the American College of Cardiology, and nine other health organizations state that high blood pressure, or hypertension, is now defined as 130 and higher for systolic blood pressure (the top number), or 80 and higher for diastolic blood pressure (the bottom number).1

Side Effects

What Scott really hated about being on medications was how crummy he felt. “I was tired a lot, I had a dry hacking cough that never seemed to go away, and erection problems that weren’t going away either. My doctor said they were side effects from the pills, or from the high blood pressure itself, and this was just going to be life from here on out.”

Alternatives To High Blood Pressure Medication

It wasn’t the life Scott wanted. He started researching lifestyle alternatives to blood pressure drugs, found the Pritikin Program, and started revamping his life.

Every morning, he got up an hour earlier to exercise. He cut out fast food completely and embraced the Pritikin Eating Plan. He traded burgers and fries for foods like salmon, roasted sweet potatoes, and big green salads. He filled his refrigerator with veggies and put a big bowl of fruit on the kitchen table, which he re-stocked every other day.

Within 10 days, “my doctor did something amazing. He took me off two of my medications and cut the dose of the third in half. That was three months ago. I’m now off all medications. And my blood pressure is 115/70.

“I’ve got my life back”

“What’s really amazing is that all the side effects from the meds are gone. I’ve got my life back. I honestly didn’t think I could ever feel this good again.”

Effects of Lifestyle Change

Scott is not alone. Large scientific studies published over the last two decades have affirmed the power of lifestyle changes like healthy food and exercise in lowering and controlling blood pressure.

Here are research highlights:

  • Dietary Approaches to Stop Hypertension (DASH)

    Several studies funded by the National Institutes of Health have found that the DASH diet lowers blood pressure as well as or better than medications. DASH, similar to the Pritikin Program, promotes menus that are high in fruits, vegetables, whole grains, and beans; low in fats, salt, cholesterol, red meats, and sweets; and moderate in fish, poultry, nuts, and low-fat or nonfat dairy foods.

    The NIH researchers found that eight weeks of DASH eating resulted in reductions in blood pressure in all groups of men and women studied. Even those with normal blood pressure (systolic pressure less than 120) had a small drop.

    A healthy lifestyle like the Pritikin Program is a safe, scientifically proven alternative to high blood pressure medication.

    The biggest reductions in blood pressure were observed in the individuals who were hypertensive, “emphasizing the fact that diet is a major factor in determining blood pressure in most hypertensive patients,” notes Dr. James Barnard, UCLA scientist and author of 200+ studies on the link between lifestyle and cardiovascular diseases like hypertension.

    In another part of the DASH studies, three groups of people followed the DASH diet but with varying levels of sodium intake (3,300, 2,400, and 1,500 mg a day). The researchers found that the biggest drops in blood pressure occurred in the group on the 1,500 mg-of-sodium-a-day diet.2

  • Pritikin Program

    Seven studies have been published demonstrating that the Pritikin Program of eating, exercise, and lifestyle-change had quick and profound blood-pressure-lowering benefits for individuals with hypertension.

    Researchers combined the data from all seven studies, which totaled 1,117 people with hypertension who had come to the Pritikin Longevity Center for an average of three weeks. In this large population, blood pressure was reduced to normal or near normal levels. Moreover, a little more than half of the 598 patients initially taking blood pressure medications were able to stop taking their drugs.3

  • Lifestyle Change and Resistant Hypertension

    Between 20 to 30% of the 70 million Americans with hypertension have developed resistant hypertension, which means that blood pressure remains high despite being on three or more anti-hypertensive drugs. The disease, in effect, resists the drugs.

    But recently, scientists found that resistant hypertension does in fact respond beautifully to lifestyle changes. Just one week of eating a very low-sodium diet (1,150 mg of sodium daily) sent blood pressure plummeting to normal or near-normal levels.4

    The subjects spent a second week eating a high-salt diet – 5,700 mg of sodium daily. At the end of the week, their blood pressures had shot right back up to 146/80 – nearly identical to their pre-study levels.

    These findings, summed up lead investigator Dr. Eduardo Pimenta of the University of Alabama, “suggest that patients with resistant hypertension are particularly salt-sensitive and emphasize the importance of low dietary salt in the clinical management of resistant hypertension.”

    Observes Kimberly Gomer, MS, RD, Director of Nutrition at the Pritikin Longevity Center in Miami, Florida: “Had the subjects in this study exercised, lost excess weight, and consumed a healthier diet overall, as we teach our guests here at Pritikin, the drops in blood pressure would likely have been even more impressive.”

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American Heart Association

So strong is the research affirming the value of lifestyle change in preventing and controlling hypertension that the American Heart Association, among several leading health organizations, now teaches that a healthy lifestyle is “critical for the prevention of high blood pressure and an indispensable part of managing it.”5

Key lifestyle recommendations of the American Heart Association mirror the Pritikin Program and include:

  • Eating a healthy diet focused on fruits, vegetables, whole grains, beans, fat-free dairy products, skinless poultry, and fish; and limiting added sugars, saturated fats, trans fat, and sodium (no more than 1,500 mg of sodium a day)
  • Exercising regularly
  • Maintaining a healthy weight
  • Managing stress, including regular practice of relaxation techniques like yoga
  • Avoiding tobacco smoke
  • Limiting alcohol consumption

Three Key Recommendations

If you wish to explore lifestyle alternatives to high blood pressure medication, the physicians at the Pritikin Longevity Center recommend the following:

1

Do not make changes to your blood pressure medication on your own.

It is critical you meet with your doctor. Abruptly stopping any medication used to treat high blood pressure could be very dangerous. Your blood pressure may rise, putting you at risk for a heart attack, stroke, and other life-threatening conditions.

2

Be leery of herbal therapies.

On the internet and elsewhere, you’ll undoubtedly find glowing “reports” about herbs like snakeroot, hawthorn, and ginseng for the treatment of high blood pressure. Don’t be swayed. Herbal therapies have not been extensively studied. What’s worse, some carry potential health risks, particularly if you’re using them in combination with high blood pressure drugs.

If you plan to take herbal therapies, speak to your doctor first.

Above all, keep in mind that the word “herbal” is not synonymous with “natural.” Because of their strong potency and potential side effects, many herbs actually have a lot more in common with drugs than with nature.

3

If you begin a healthy lifestyle like the Pritikin Program, be prepared for results to happen quickly.

Keep in very close touch with your doctor for close monitoring of your blood pressure and medication needs.

“We have many people with hypertension who come to the Pritikin Longevity Center,” observes Associate Medical Director Danine Fruge, MD, “and within three days, many have blood pressures that have dropped so low that we need to reduce their medications or take them off their pills altogether. Yes, just three days. That’s how quickly and powerfully our bodies respond to healthy food, exercise, and other lifestyle changes.

“I used to think these dramatic drops in blood pressure were something that happened to only a very few people. But I’ve been here at Pritikin for 14 years, and I see results like these every week. This isn’t a miracle. It’s simply what happens when we start taking good care of ourselves.”

Several studies, as noted earlier, have found that within about three weeks, significant lowering of blood pressure occurred among the majority of people who came to the Pritikin Center.

A key take-away for many guests at Pritikin is the education they receive. “I knew I had to lower my sodium intake,” says Pritikin alumnus Juan O of Stonington, Connecticut, “but before coming to Pritikin, I didn’t really know how to do it.

“I thought, for example, that simply removing the salt shaker from my kitchen would solve the problem. I had no idea that 80% of the sodium Americans eat comes from outside the kitchen – from restaurant meals and commercially processed foods like breads, soups, and salad dressings.”

Cut Salt, Save Lives

Research published in the journal Hypertension by scientists at the University of California, San Francisco, underscored how important it is for Americans to curtail their salt intake.6

Using mathematical models, the researchers determined that immediately reducing people’s salt consumption from current levels – 3,500 mg daily – to the upper limit of the U.S. government guideline – 2,300 mg daily – would save 500,000 to 850,000 lives over the next decade, largely by reducing heart attacks and strokes related to hypertension.

Hypertension Diet

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More Health Benefits

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The scientists also estimated that reducing sodium intake to 1,500 mg daily, as recommended by the Pritikin Program and the American Heart Association, would save up to 1.2 million lives over the next decade.

Bottom Line

  • First and foremost, get your blood pressure under control.

    “The higher your blood pressure, the higher your risk of stroke, heart attack, congestive heart failure, kidney disease, impotence, and dementia,” states Dr. Seth Marquit, MD, Medical Director at the Pritikin Longevity Center.

    Hypertension is the #1 risk factor for strokes, and nobody wants a stroke. Of the 750,000 Americans who suffer a stroke each year, more than 150,000 die of it. Most of the rest suffer some permanent brain damage. What’s more, stroke is the #1 reason Americans end up in nursing care facilities.

  • Second, consider science-based alternatives to high blood pressure medications, particularly a healthy lifestyle.

    That’s because a healthy lifestyle like Pritikin can not only help lower blood pressure, it can also help protect against many other major health concerns like heart disease, diabetes, obesity, and even some forms of cancer. No pill has that kind of power.

  • Third, go all in.

    “Don’t procrastinate or make half-hearted attempts. After all, this is your life,” counsels Dr. Marquit.

    “If you can, take advantage of in-residence programs like the Pritikin Longevity Center. They give you everything you need under one roof – physician supervision, exercise training, a complete education in living well, good food, and, maybe most importantly, time away from salt, sugar, and grease so that your palate has a chance to rediscover the good flavors of good food.”

    Agrees former fast food eater Scott, our electrical engineer from L.A. “I’m actually happy with what I’m eating now. I used to crave pepperoni pizza. I now wake up every morning craving big juicy navel oranges. Me! Who knew?! And I like the fact that there’s plenty to eat on Pritikin. I’m never hungry.”

    Sums up Dr. Marquit: “We all want to enjoy our lives and do what we want to do for as long as we can. Programs like Pritikin give us the tools to make it happen.”

Super-Simple Meal Plan For Blood Pressure and Weight Loss

Want to lower blood pressure and shed weight, but hate to cook? We have the solution.

Sources

1 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
2 New England Journal of Medicine, 2001; 344: 3.
3 Journal of Applied Physiology, 2005; 98: 3.
4 Hypertension, 2009; 54: 475.
5 American Heart Association
6 Hypertension, 2013; 61: 564.

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MEDSAFE

Published: May 2003

I’ve Missed a Dose; What Should I Do?

Information on this subject has been updated. Read the most recent information.

Prescriber Update 24(1): 14
May 2003

Andrew Gilbert, Libby Roughead and Lloyd Sansom, Quality Use of Medicines and Pharmacy Research Centre, University of South Australia, Adelaide

Reprinted from Australian Prescriber 2002;25(1):16-18 with permission.

More than 80% of patients occasionally miss a dose of their medication. Health practitioners ought to plan with their patients what to do if a dose is missed. Patients believe that this plan should be a required part of the information received when a medication is prescribed and dispensed. Consumer Medicine Information sheets, which are available for most commonly prescribed medications, contain a section on what to do if a dose is missed. The routine use of these sheets or similar advice may help patients to know what to do when they miss a dose.

Introduction

Why don’t consumers know what to do when they miss a dose of their medication? As health professionals we know that the vast majority of patients occasionally miss a dose of their medication. This unintentional non-compliance, and request for advice after the event, is very common in practice. In a study of 205 people, 90% rated having information on ‘what to do if a dose is missed’ as very important or important and only 1.5% did not want information on this topic. 1 A USA study2 found that less than 50% of patients received this information.

Given our understanding of the difficulties around compliance with medication regimens, it must be our expectation that many patients will miss doses. Informing them about what to do about a missed dose at the time of prescribing, dispensing and administration would seem to be a logical step towards improved compliance.

Pre-emptive advice

Missed doses could be viewed within the framework of patient non-compliance, however the problems which arise often result because health professionals do not give enough information to allow the patient to safely use the medication. Teaching a patient what to do if a dose is missed and providing strategies to minimise the number of missed doses appears a sensible approach.3 Providing written information, that includes what to do if a dose is missed, improves people’s self-administration of medicines, including corrective action when a dose is missed.4

In practice, giving information on what to do if a dose is missed should not be too onerous a task for medical practitioners or pharmacists. Most of the commonly prescribed medications in Australia come with, or have available, a Consumer Medicine Information (CMI) sheet.a All CMI sheets have a section entitled ‘What to do if you miss a dose’. Giving patients a CMI sheet the first time they receive a medication, and using this material in discussion with patients at the time of prescribing and dispensing would prepare them for this eventuality.

Assessing the importance of a missed dose (Table 1)

The severity of the patient’s condition, whether clinically significant breakthrough effects are likely to be observed, and the characteristics of the medication should be considered when deciding the most appropriate strategy following a missed dose. Vulnerable patients are easily recognisable in any practice and include those on medications of low therapeutic index,b or suffering from conditions which require constant maintenance of therapeutic concentrations (for example epilepsy and thromboembolic diseases requiring anticoagulation). On the other hand, for most people with hypertension or hypercholesterolaemia a single missed dose will be of little consequence.

The patients should be informed at the time of prescribing and dispensing, of strategies to minimise missed doses and to redeem the situation when a dose is missed. Highlighting the strategy as it appears on the CMI or writing out an action plan as a reminder to the patient may prove very useful.

While a pre-emptive approach is ideal it is recognised that requests for information about missed doses are common. Knowledge of a drug’s half-life, a major determinant of the fluctuation in interdose concentrations at steady state, is useful for making recommendations on what to do if a dose is missed. Upon cessation of therapy, it takes four to five half-lives for the drug to be completely eliminated.

In general, medications, or their active metabolites, with a long half-life tend to create less problems when a dose is missed than medications with a short half-life. However, the clinical effect of some drugs is not related to the half-life. This usually occurs when the drug is acting via an irreversible mechanism (for example aspirin’s effect on platelets), via an indirect mechanism (for example the effect of warfarin on blood coagulation), when the drug is a pro-drug (in which case it is the half-life of the active species that is important) or when the drug is converted to an active metabolite which has a long half-life.5

Missing several consecutive doses raises additional problems. For example, for drugs with long half-lives it can take a significant time to re-establish therapeutic concentrations when regular dosing resumes unless loading doses are given (for example digoxin). Drugs with short half-lives will lose therapeutic effect rapidly. Further, drugs with first-dose effects, for example an ACE inhibitor in combination with diuretics, may also present clinical problems when normal dosing is resumed. Overall, surprisingly few studies have examined the clinical significance of a missed dose.

Missed doses of the oral contraceptive pill have been well studied. Women taking the pill need to be aware of the risk associated with missed doses and of what to do when a dose is missed (Table 1). Given the complexity of this information, and the risk of an unwanted pregnancy, it is important that any verbal counselling is supported with appropriate written material. Where a CMI sheet is available this can be used during the consultation. If no CMI sheet is available for the prescribed product, written notes based on the recommendations in the Australian Medicines Handbook are useful.6

Conclusion

For the vast majority of patients an occasional missed dose will have little impact on the outcome of therapy. Most CMI sheets include statements such as:

  • If you forget to take one or more doses: take your next dose at the normal time and in the normal amount. Do not take any more than your doctor prescribed.
  • If you miss one dose, skip it and continue with your normal schedule.

Having this knowledge when starting therapy may be a simple way to alleviate much patient anxiety and in some cases avoid unwanted clinical consequences.

a In New Zealand, CMI fact sheets are available for some medicines. These CMI can be freely accessed from the Medsafe web site: www.medsafe.govt.nz/Medicines/infoSearch.asp

b The therapeutic index reflects the range of concentrations between the drug concentration which produces toxic effects and the drug concentration required for therapeutic effects. A narrow therapeutic index means only small increases in concentration can cause toxicity and small decreases in concentration can result in loss of efficacy.

Conflict of interest: none declared

  1. Howard J, Wildman K, Blain J, Wills S, Brown D. The importance of drug information from a patient perspective. J Soc Admin Pharm 1999;16:115-26.
  2. Lyons RF, Rumore MM, Merola MR. An analysis of drug information desired by the patient. J Clin Pharm Ther 1996;21:221-8.
  3. Zind R, Furlong C, Stebbins M. Educating patients about missed medication doses. J Psychosoc Nurs Ment Health Serv 1992;30:10-4.
  4. Paulson PT, Bauch R, Paulson ML, Zilz DA. Medication data sheets – an aid to patient education. Drug Intell Clin Pharm 1976;10:448-53.
  5. Sansom L, editor. Australian Pharmaceutical Formulary and Handbook. 17th ed. Canberra: Pharmaceutical Society of Australia; 2000.
  6. Australian Medicines Handbook 2000. 2nd ed. Adelaide: Australian Medicines Handbook Pty Ltd.; 2000. p. 17-9.
Table 1

Examples of medications for which missed doses may be clinically important, and information for patients on what to do if a dose is missed

Medication Information for consumers
Oral contraceptives
Combined oral contraceptives If one or more tablets are missed from the inactive tablets, no additional contraceptive precautions are necessary, and tablet taking should be recommenced ignoring the missed tablet or tablets.
However, if all the inactive tablets are missed and then the next pack is not started on time, start as soon as it is remembered. Additional contraception (such as a condom or a diaphragm) must be used for the next 7 days.
If an active tablet is forgotten take it as soon as it is remembered, within 12 hours after the time that it is normally taken. Then take the next and subsequent tablets at the usual time.
If there is a delay of more than 12 hours after the time that the tablet is normally taken, contraceptive protection in this cycle may be reduced. There is more risk in becoming pregnant if tablets are missed during the first week, or at the end of the current pack. Take the missed tablet as soon as it is remembered, even if this means taking two tablets at the same time. Any earlier missed tablets are left in the pack. Continue taking a daily tablet as usual, and use additional contraceptive precautions (except for the rhythm or temperature method) for the next 7 days. If these 7 days extend into the inactive section, skip the inactive section and start a new pack in the active area on the next day instead
Progestogen-only oral contraceptives For women using the progestogen-only pill the recommendation for the use of other methods of contraception is extended to 14 days if the dose is delayed by three hours or more.
Anticonvulsants
Acetazolamide
Carbamazepine
Ethosuximide
Phenytoin
Tiagabine
Topiramate
Vigabatrin
If it is almost time for next dose (within 4 hours), skip the missed dose and take the next dose when it is due. Otherwise, take it as soon as it is remembered, and then go back to taking the medicine as usual. Do not take a double dose to make up for the missed dose. This may increase the chance of you getting an unwanted adverse effect.
Lamotrigine
Sodium valproate
Do not take a double dose to make up for the dose that you missed. (This drug has a long half-life.)
Digoxin
Warfarin
If it is almost time for the next dose, skip the missed dose and take the next dose when it is due. Otherwise, take it as soon as it is remembered, and then go back to taking the medicine as usual. Do not take a double dose to make up for the dose that you missed.
Psychotropics
Lithium If it is almost time for the next dose (within 2 hours), skip the missed dose and take the next dose when it is due. Otherwise, take it as soon as it is remembered, and then go back to taking the medicine as usual. Do not take a double dose to make up for the dose that you missed.
Antidepressants other than monoamine oxidase inhibitors
Monoamine oxidase inhibitors
If it is almost time for the next dose, skip the missed dose and take the next dose when it is due. Otherwise, take it as soon as it is remembered, and then go back to taking the medicine as usual. Do not take a double dose to make up for the dose that you missed.
Phenelzine Tranylcypromine Do not take an extra dose. Wait until the next day and take the normal dose then.

What time you take blood pressure pills matters

How big a problem is non-dipping?

“I think it’s huge,” says Hopkins’ Dr. Lawrence Appel. “This is our best lead” into why black Americans with kidney disease, in particular, tend to worsen despite treatment.

Appel found 80 percent of black kidney patients in a recent study were non-dippers. Most startling, 40 percent had nighttime blood pressure that was even higher than daytime levels.

Two-thirds of chronic kidney disease patients, and at least 10 percent of the general population, are estimated to be non-dippers, says Dr. Joseph Vassalotti of the National Kidney Foundation. One theory is that their bodies have trouble excreting salt.

Yet few patients have ever heard of the problem — and few doctors know who is affected. Most people get their blood pressure checked only during the day. A 24-hour blood pressure monitor can tell but is rarely used, partly because insurance seldom pays for the extra visit to download and diagnose the readings.

And most patients who take several once-a-day pills swallow them all in the morning, meaning they all start wearing off around the same time, says Dr. Gina Lundberg of St. Joseph’s Hospital in Atlanta.

Spreading out doses
“It does make good sense to take some in the morning and some in the evening,” says Lundberg, a spokeswoman for the American Heart Association.

Everyone has an internal clock, determined by genes, that affects health. Many of these biological rhythms are circadian, meaning they fluctuate on a 24-hour cycle.

Consider how that can affect the timing of treatments. Some older “statin” pills fight cholesterol best if taken at bedtime; they target a liver enzyme that’s most active at night. Asthma attacks are more frequent at night, and the stomach secretes more heartburn-causing acid at night, affecting some patients’ dosing requirements. Researchers even are studying how to better time certain cancer chemotherapies and allergy treatments.

The best-known example: Blood pressure jumps in the early morning hours, as the awakening body produces more stress hormones. That’s also why heart attacks and strokes are most common in the morning.

The nighttime dipping problem has gotten far less attention. The new Italian study marks an important advance, says Dr. Mahboob Rahman of the University Hospitals of Cleveland.

“We know now that you can change medication timing and lower blood pressure at night,” he explains.

That doesn’t mean everyone should switch willy-nilly to bedtime dosing. Morning may be best for people on just one drug, and no one yet knows if the switch truly gives non-dippers better overall health. “That’s the million-dollar question,” Rahman cautions.

Still, Lundberg says it’s worth asking your doctor how to time doses, saying one at night for someone taking multiple medicines couldn’t hurt.

Double the dose of antihypertensive meds?

A 50-year-old man returns for follow-up of hypertension. He is currently taking 20 mg of lisinopril. His blood pressure readings over the past month are 150/96, 155/98, 160/94, and 162/96. His renal function is normal, and he has been taking his lisinopril regularly.

What do you recommend?

A. Increase his lisinopril to 20 mg twice a day.

B. Switch to valsartan.

C. Add amlodipine.

Dr. Douglas S. Paauw

For many years, we have been taught to always maximize the dose of one medication before adding another medication. This has historically been the case for hypertension management.1 The thought process has been that, if you add an additional medication, you add more potential side effects and added cost.

But is there much benefit in doubling the dose of antihypertensive medications?

H.J. Gomez and colleagues studied the dose response of lisinopril in essential hypertension.2 Patients received very-low-dose (1.25 mg or 5 mg), moderate-dose (20 mg), or high-dose (80 mg) lisinopril. The difference in blood pressure reduction between 20 mg and 80 mg was modest (5 mm/3 mm less in those receiving 80 mg, compared with 20 mg). There was no clinical effect at 1.25 mg of lisinopril, but a relatively flat dose response above 20 mg.

A similar finding was reported by J.R. Benz and colleagues in regard to escalating doses of valsartan.3 The study looked at blood pressure in response to valsartan at doses of 80 mg and 160 mg, and in combination with hydrochlorothiazide. The difference in blood pressure between valsartan 160 mg and 80 mg was 3 mm/0.8 mm. The difference in blood pressure between patients taking 80 mg of valsartan and 25 mg hydrochlorothiazide, compared with those taking 80 mg of valsartan, was 12/6.

In a meta-analysis of 354 randomized trials of fixed-dose blood pressure medications, M.R. Law and colleagues found that cutting the doses in half only reduced effectiveness of lowering BP by 20%.4 The average reduction in systolic BP was 9.1 mm Hg, and reduction in diastolic BP was 5.5mm Hg – which only was reduced to 7.1 mm Hg/4.4 mm Hg when the doses of medications were cut in half. Side effects attributed to beta-blockers, calcium channel blockers, and diuretics were very dose related, whereas the side effects attributed to ACE inhibitors were not.

In another meta-analysis comparing monotherapy vs. combination therapy for lowering blood pressure, adding another drug lowered blood pressure fivefold more than doubling the dose of the initial antihypertensive drug.5

I think the right answer in this case would be to add amlodipine instead of doubling the dose of lisinopril or switching to valsartan as a single agent. The data are striking on how little effect there is in increasing antihypertensive medication doses. Adding another antihypertensive medication should be the standard practice when the first medication started does not achieve the desired goal.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected]

1. JAMA. 2003 May 21;289(19):2560-72.

2. Br J Clin Pharm. 1989;28:415-20.

3. J Hum Hypertens. 1998 Dec;12(12):861-6.

4. BMJ. 2003 Jun 28;326(7404):1427.

5. Am J Med. 2009 Mar;122(3):290-300.

Your doctor may prescribe medication you can take to lower high blood pressure. If complications associated with high blood pressure are present, other drugs may also be prescribed. Whatever the treatment prescribed for you, it is a good idea to keep the following guidelines in mind when you’re taking prescription drugs.

  • Know the names of your medications and how they work. Know the generic and brand names, dosages, and side effects of the drugs. Always keep a list of your medications with you.
  • Let every doctor you see know what drugs you take and if your medication or dosage has changed since your last visit.
  • Take medications as scheduled, at the same time every day. Do not stop taking or change your medications unless you first talk with your doctor. Even if you feel good, continue to take your medications. Stopping drugs suddenly can make the condition worse.
  • Have a routine for taking medications. For example, using a pillbox marked with the days of the week, fill the pillbox at the beginning of each week to make it easier to remember.
  • Keep a medication calendar and note every time you take a dose. Prescription labels tells you how much to take at each dose, but your doctor may change the dosage periodically, depending on your response to the drug. On your medication calendar, you can list any changes in dosages as prescribed by your doctor.
  • Do not decrease your medication dosage to save money. You must take the full amount to get the full benefits. If cost is a problem, talk with your doctor about ways you can reduce the costs of your medications.
  • Do not take any over-the-counter drugs or herbal therapies unless you ask your doctor first. Some drugs may interact with each other, causing undesirable effects.
  • If you forget to take a dose, take it as soon as you remember. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take two doses to make up for the dose you missed.
  • Regularly fill prescriptions and ask the pharmacist any questions you have. Do not wait until you are completely out of medication before filling prescriptions. If you have trouble getting to the pharmacy, have financial concerns, or have other problems that make it difficult for you to get your medications, let your doctor know.
  • When traveling, keep drugs with you so you can take them as scheduled. On longer trips, take an extra week’s supply of medications and copies of your prescriptions, in case you need to get a refill.
  • Before having surgery with a general anesthetic, including dental surgery, tell the doctor or dentist in charge what drugs you are taking. An antibiotic may need to be prescribed prior to a surgical or dental procedure. Also, let the doctor know if you are taking aspirin and/or any other blood thinners.
  • Some drugs may alter your heart rate, so take your pulse regularly.
  • Drugs that relax constricted blood vessels may cause dizziness. If you experience dizziness when standing or getting out of bed, sit or lie down for a few minutes. This will increase your blood pressure. Then get up more slowly.

Talk about injecting some unwelcome anxiety into a holiday or business trip.

You go to Manhattan and your checked luggage heads to Moose Jaw – with your medication inside it. Or you arrive at your destination and realize the pill organizer you planned to pack is still sitting on your dresser back home. Or your trip gets extended and you don’t have enough drugs to cover the extra time.

Arnie Salmon, of Beechwood, N.B., knows too well the sinking feeling that comes with finding yourself in one of these scenarios.

Salmon, 47, takes two pills daily to control his blood pressure. Early this year he set off for Slave Lake, Alta., to take a job working on a pipeline. Snowstorms turned Salmon’s journey into a marathon, forcing layovers in Montreal, Toronto and Saskatoon.

Some 40 hours later, Salmon finally arrived in Edmonton. But his suitcases did not. Unfortunately, Salmon had packed his medication in his checked luggage, figuring in the post 9-11 world he wouldn’t be allowed to carry them onboard.

In Slave Lake, he was immediately thrust into a gruelling schedule of 12-hour days and seven-day weeks of high stress work.

“By the fourth or fifth day, I was shaking. I was desperate for my (medication),” he recalls in a recent interview from New Brunswick.

He pleaded for time off and headed for the emergency department of the local hospital. There a doctor called back east to confirm what Salmon took and wrote him a replacement prescription. Salmon’s luggage eventually arrived in Slave Lake two weeks after he did.

While an emergency room solved Salmon’s problem, in many cases a visit to a pharmacist can be the answer to the dilemma of the missing meds.

“If you lose your medication or forget them at home and you’re travelling within Canada, often you can go into a pharmacy and pharmacists are authorized to renew prescriptions in that situation,” says pharmacist Brian Stowe, who runs The Prescription Shop, a pharmacy on the campus of Carleton University in Ottawa.

“They would give you an appropriate amount of medication for the time you need it.”

Rules governing what pharmacists can and can’t do vary from province to province. In Alberta, for instance, pharmacists have the authority to prescribe some drugs, approve some prescription refills and give vaccinations.

But even in provinces where pharmacists don’t have those powers, there is some leeway to help people who need a few days worth of pills because they are in a pickle, Stowe says.

In some cases, a pharmacist might direct the person to a walk-in clinic to get a new prescription, or might call the person’s pharmacy at home to verify which drugs are needed and at what dose.

“Or if you run out and you’ve got the bottle, we might give you a few pills to get you through the weekend. Again, that’s at the discretion of the pharmacist. And it will depend on the medication,” says Stowe.

Canadians who find themselves in this kind of bind while travelling in the U.S. could find pharmacists similarly amenable to helping out – as long as they can find a way to verify what the patient is supposed to be taking and at what dose.

“I think most of the time the pharmacists are able to deal with it,” says Carmen Catizone, executive director of the U.S. National Association of Boards of Pharmacy, an organization representing state bodies that govern the conduct of pharmacists.

“Because… with 24-hour pharmacies they can call up in Canada and say ‘I have a patient of yours here. I just want to confirm this. I’m going to give them a couple of day’s supply.'”

“I think there’s a good rapport and a good professional relationship that goes on between the Canadian and U.S. practitioners.”

But like Stowe, Catizone cautions that a pharmacist’s willingness to help a traveller in need will depend on the drugs being asked for. Blood pressure or cholesterol lowering medication? Sure thing. Prescription painkillers or prescription sleeping pills? Probably not.

“I can tell you if it’s a controlled substance, a pain medication or something like that,… they’re going to be less than eager to try to get that filled from a Canadian doctor that’s not licensed in the U.S.,” Catizone says.

Stowe says he urges people on medication to carry a wallet-sized card listing the drug, the dose and the drug’s generic name (brand names can differ from country to country). That way if they are ever separated from their medication, they have something to show the pharmacist or doctor they consult for help. Most pharmacies can make up such a list for clients, he says.

As for Salmon, he has no intention of repeating his Slave Lake problem in future travels.

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“If there’s medication you have to have on a daily basis, I guarantee it will be on my person,” he insists. “And enough to carry me through – even a month’s supply.”

“Because once you get someplace, you don’t know how long it will be before you can finally get to a doctor who can actually get ahold of someone from where you’re from and actually fix your problem for you.”

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This is not the first time that this has happened, but I sure do hope it will be the last. I left for a weekend in Maine without Edward’s medicine. My wife gave me a list, and I checked it twice. I packed everything on that list, triple checking the medications for the children. And then Edward decided to throw a fit about something involving his suitcase, and he didn’t want to pack his toothbrush, and he was taking things out of his bag, so I took the medicine out, to protect it, and set it down next to his bag on the table. This would prevent him from throwing it somewhere, and ensure that I would remember to put it back in. I did not remember to put it back in. In my mind it was already packed and checked off of my mental list. I did not remember to put it back in. Stupid. Idiot. The worst father ever.

But wait! There is hope! This is not the first time this has happened! I know now that if you ever forget medication while travelling, you can go to any pharmacy and get an emergency supply. They will often just give you the medicine and subtract it from your next refill! Now, there are some restrictions. They need your prescription info. So the easiest thing to do would be to find the local branch of your pharmacy, since they will already have your information on file. No muss, no fuss, no hoops, no jumps, just medicine. Otherwise you need to call your local pharmacy back home and have them call it in to the nearest place to where you are.

I called the nearest branch, 20 minutes away, and the woman on the phone confirmed that yes, they had our information, and yes, they had the medication, and yes, I could drive over right then and pick it up. Since we had discovered my failure only at bedtime the night before, it was now morning and one dose had already been missed. We were pushing two doses missed. So, despite his protests, we bundled up the boy and stuffed him into my Dad’s car, while Ruby stayed behind to play with Grammy. I felt terrible, but at least we were going to get the pills we needed.

When I got to the pharmacy, the sole employee of the day was on a phone call, so I waited patiently behind the counter. And then I waited some more. A man came and stood behind me. Then a family came and stood behind him. Ten minutes passed. A long line was forming. The phone call continued. I started to freak out. He needed his medicine! Get off the phone! Seriously! She smiled apologetically at me and continued to speak on the phone while typing things into her computer. At the fifteen minute mark I was more than annoyed.

Finally! Off the phone and apologizing for the wait, she walked over and asked how she could help me. I no longer cared about being upset about the wait; I just wanted the medicine, and quickly. That was when she informed me that she had been mistaken over the phone earlier. They did not, in fact, have the medication in stock. I mean, they had it, but not in the right exact dose. But could we just take twice as many, or half as many? Wasn’t there some close approximation that could get my son the dose he needed? Nope. That’s not how it works. They need to give out only exactly what the prescription says. No substitutions. At all. But do not despair! She had called around and found another pharmacy, only 10-15 minutes further away in the wrong direction, that did have it. So we could just go there.

Back into the car, my self-loathing only increasing, we sped off to what my father called “the bad part of town,” to find the Walgreens that had the medicine. As we parked the car, I saw an older man slowly walking in the front door. There was no doubt in my mind that he was headed for the pharmacy, and that he was going to be in front of me in line, and that he was going to take forever. I dashed forward, sprinting through the automatic doors, scanning the store for him. There he was, puttering down an adjacent aisle, headed straight for the pharmacist. I took a parallel course down the aisle next to his and bolted for that counter, reaching it just ahead of him. Ha HA! Take that, older gentleman that probably needs something and was technically almost here first! Yeah, there is nothing about this whole story that I am proud of.

So finally, the man behind the counter has the medication. Oh, but our insurance is no good here. Because it is not our normal pharmacy, they can’t just take it out of the next refill. They are going to charge me, $31 for one day’s worth of medicine. A costly mistake. I know that in the grand scheme of things $31 is not the universe, but the week after Christmas, with a bank account threatening to implode, this was enough to make me want to burst into tears at the counter. But I did not cry. I paid the man and took the medicine to my son, who happily swallowed it down with some special beverage that he was rewarded with. Edward was fine. There were no complications. We finished the rest of the visit in peace.

I wish I could say, thanks to the turmoil of these events, that this will be the last time I ever forget an important medication on a trip. I wish my brain worked in such a way as to actually learn and improve from such things. But I fear it is not true. And I know I can chalk it up to the mysteries of ADHD, but somehow that doesn’t make me feel any better, or any less guilty. The only consolation that I have, comes from knowing that, if I screw up, there is help available. And no matter how much red tape I have to cut through, there are pharmacies on practically every corner, and there is medicine to be had.

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If you lost your medicine while travelling, what would you do?

April 7, 2015 in Travel Health • By Miles Varn

Whether you’re travelling across the country to visit family or across the globe for business, it’s smart to have a plan in place in case you need medical care. That’s especially true if you use medication to help manage a chronic health condition such as heart disease, high blood pressure, diabetes, asthma, or chronic obstructive pulmonary disease (COPD).

Preparations before you travel

Before your trip, ask your doctor for a copy of prescriptions of all medicines you take regularly and carry them in your wallet or carry-on bag. You should also put your prescription medicines in your carry-on so you’ll have them if you need them on a long flight or if your checked luggage gets lost.

Especially when travelling overseas, it’s wise to keep medications in their original prescription bottles. For injectable medications and medications that fall into the category of controlled substances, such as certain pain medications, sleeping pills, ADHD medications, and medications for treatment of anxiety and depression, ask your doctor to provide you with a letter on his or her stationery that verifies your need for the prescription. If you’re travelling to an overseas destination you’ve never visited before, check with the American Consulate or Embassy to find out if you can bring your medications with you. Some countries do not allow visitors to bring certain drugs with them.

Drug names and dosages can vary from country to country, so ask your pharmacist or doctor to provide you with the generic names for all prescription and over the counter medications you take regularly so that you know what to ask for if you need to fill a prescription while you’re travelling.

You forgot your medication. What should you do?

If you forget or lose your medications while travelling, they can be difficult to replace. In the U.S., you can call your doctor’s office and ask for a refill to be faxed or called into a pharmacy at your destination, though that can be difficult on weekends and after office hours.

When travelling outside the country, replacing lost or forgotten medications can be a good bit more complicated. On a trip to China, after landing in Beijing, one of our members found that none of the medications she took regularly were in her suitcase.

“I wasn’t sure if I had left them at home, if they were confiscated by airport security or stolen from my bag,” she explained. “Whatever the reason, I was absolutely panic-stricken and decided to call the PinnacleCare Health Advisor Hotline. The on-call health advisor told me I would have to be seen by a local doctor in China before I could receive any replacement medications. She quickly added that she would make all of the necessary arrangements. As promised, the advisor scheduled me an appointment with a Canadian doctor in Beijing the next morning. I loved the doctor and got the medications I needed. I don’t know what I would have done without my advisor’s help!”

Find out more about how a health advisor can help you get the medical care and support you need anywhere in the world.

Forgetting to Take Your Blood Pressure Medication?

It’s not always easy to remember to take your blood pressure medication, but it’s vital that you do: If you have high blood pressure, or hypertension, medications can lower blood pressure and help prevent serious health conditions, including heart attack, stroke, kidney disease, and congestive heart failure.

Get in the Habit of Taking Your Blood Pressure Medication

If you often skip doses of your blood pressure medication or you don’t take it as recommended, your hypertension could get out of control. The following tips to help you remember to take your blood pressure medication regularly:

  • Remind yourself why you’re taking blood pressure medication. “Take a step backward and say to yourself, ‘Why am I taking this medication to begin with?’”, says David Meyerson, MD, JD, director of cardiology consultation services at Johns Hopkins Bayview Medical Center and national spokesperson for the American Heart Association.. He recommends that you think about why your doctor wrote you a prescription for blood pressure medication in the first place, and use that answer as motivation. Another motivator: Family history. Many people with high blood pressure have family members who have had strokes or heart attacks. “You have to understand that history will repeat itself unless we do something to interrupt it,” says Meyerson.
  • Keep your blood pressure medication in a convenient location. Put it where you’ll see it, such as on the nightstand by your bed. Meyerson says that many people intend to take their blood pressure medication before leaving the house in the morning, but then don’t. If this sounds familiar, Meyerson suggests keeping a few pills with you or in your desk at the office, in case you miss your morning dose.
  • Keep your prescription filled. Another common reason that people miss doses of their blood pressure medication is because they run out before getting a hrefill. “Plan ahead so that you don’t run out,” says Meyerson. To help you with this, try making a note in your calendar when it is time to re-order and pick up your prescription.
  • Take a medication you can afford. If the cost of your medication is keeping you from taking it as you should, talk with your doctor. “Many doctors who prescribe medications don’t actually know what the patient ends up being charged,” says Meyerson. He suggests working with your doctor to find a hypertension medication that is both effective and affordable for you.
  • Communicate any side effects you’re experiencing. Sometimes people avoid taking their blood pressure medication because it causes unpleasant side effects. Meyerson says there are many drug options for lowering blood pressure, and your doctor can find the right one for you. “The doctor has the ability to choose from a large group of medications, but he will not know if you are not tolerating a medication unless you clearly tell him,” he says.

What to Do When You Miss a Dose

“Everybody that I have ever heard of that takes a medication misses a dose from time to time,” says Meyerson. If you miss a single dose of blood pressure medication, it is usually not a problem. But it is important not to get off track about taking your blood pressure medication since regular doses can help lower blood pressure and reduce the chances that you will have blood pressure-related health problems.

“What you don’t want to do when you miss a dose is to double up the next time,” Meyerson says. If you remember at lunchtime that you missed your morning dose, it is fine to take it then, says Meyerson, but if it is late at night or the next morning that you realize it, you should resume taking your medication as directed.

Says Meyerson, “The most important thing is to get back on your regular routine.”

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