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Venlafaxine-Induced Hypertensive Emergency
Description
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A6907 - Venlafaxine-Induced Hypertensive Emergency
Author Block: Y. Mogilevskaya, S. Patel, B. A. Mina; Lenox Hill Hospital, New York, NY, United States.
Introduction:
Venlafaxine is a serotonin/norepinephrine reuptake inhibitor that is used for the treatment of depression and anxiety. It can cause elevation of blood pressure probably through noradrenergic potentiation. We present a patient who developed hypertensive emergency caused by venlafaxine.
Case:
An 81 year-old man with a history of atrial fibrillation and depression presented to the emergency room with shortness of breath and lethargy associated with epigastric pain, nausea and vomiting. He had a blood pressure of 211/142 mmHg, the rest of vital signs were within normal limits. On physical exam, he was lethargic, but arousable and appropriately answering questions. Blood work was remarkable for a white blood cell count 17.1 K/uL, creatinine 1.40 mg/dL, lactate 3.5 mmol/L. Electrocardiogram demonstrated rate controlled atrial fibrillation without ischemic changes or evidence of left ventricular hypertrophy. Computed tomography of the head demonstrated no acute pathology. Urine drug screen was negative. He was diagnosed with hypertensive emergency and admitted to the intensive care unit. He was treated with an intravenous labetalol infusion, and then transitioned to his home dose of metoprolol 100mg daily and newly added amlodipine 5mg daily. His blood pressure normalized and he was discharged home. Prior to presentation, he was never diagnosed with hypertension and has not been on any antihypertensive medications. He has regular follow-up with a primary care physician for many years and has been normotensive on office visits. He was started on venlafaxine extended release 37.5mg daily by his psychiatrist for depression one week prior to admission.
Discussion:
Venlafaxine was identified as the precipitating cause of hypertensive emergency in our patient. This medication is a known cause of blood pressure elevation, with a more pronounced increase in older patients and in men. Furthermore, its effects are dose dependent, with hypertension usually occurring at doses greater than 300mg/day. However, our patient had elevated blood pressure at a much lower dose, which may occur with individuals concomitantly taking CYP3A4 inhibitors or those who have polymorphisms of the genes CYP2D6 and CYP2C19, which are involved in the metabolism of venlafaxine. Our case underscores the importance of a careful medication review in a hypertensive individual to elucidate the cause of blood pressure elevation, especially in a patient without prior history of hypertension. Discontinuation of the offending agent will usually achieve adequate blood pressure control.
Author Block: Y. Mogilevskaya, S. Patel, B. A. Mina; Lenox Hill Hospital, New York, NY, United States.
Introduction:
Venlafaxine is a serotonin/norepinephrine reuptake inhibitor that is used for the treatment of depression and anxiety. It can cause elevation of blood pressure probably through noradrenergic potentiation. We present a patient who developed hypertensive emergency caused by venlafaxine.
Case:
An 81 year-old man with a history of atrial fibrillation and depression presented to the emergency room with shortness of breath and lethargy associated with epigastric pain, nausea and vomiting. He had a blood pressure of 211/142 mmHg, the rest of vital signs were within normal limits. On physical exam, he was lethargic, but arousable and appropriately answering questions. Blood work was remarkable for a white blood cell count 17.1 K/uL, creatinine 1.40 mg/dL, lactate 3.5 mmol/L. Electrocardiogram demonstrated rate controlled atrial fibrillation without ischemic changes or evidence of left ventricular hypertrophy. Computed tomography of the head demonstrated no acute pathology. Urine drug screen was negative. He was diagnosed with hypertensive emergency and admitted to the intensive care unit. He was treated with an intravenous labetalol infusion, and then transitioned to his home dose of metoprolol 100mg daily and newly added amlodipine 5mg daily. His blood pressure normalized and he was discharged home. Prior to presentation, he was never diagnosed with hypertension and has not been on any antihypertensive medications. He has regular follow-up with a primary care physician for many years and has been normotensive on office visits. He was started on venlafaxine extended release 37.5mg daily by his psychiatrist for depression one week prior to admission.
Discussion:
Venlafaxine was identified as the precipitating cause of hypertensive emergency in our patient. This medication is a known cause of blood pressure elevation, with a more pronounced increase in older patients and in men. Furthermore, its effects are dose dependent, with hypertension usually occurring at doses greater than 300mg/day. However, our patient had elevated blood pressure at a much lower dose, which may occur with individuals concomitantly taking CYP3A4 inhibitors or those who have polymorphisms of the genes CYP2D6 and CYP2C19, which are involved in the metabolism of venlafaxine. Our case underscores the importance of a careful medication review in a hypertensive individual to elucidate the cause of blood pressure elevation, especially in a patient without prior history of hypertension. Discontinuation of the offending agent will usually achieve adequate blood pressure control.
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