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By Holly Mansell, BSP, PharmD 
Pharmacist, Saskatchewan Transplant Program 
St. Paul's Hospital, Saskatoon, SK
As a pharmacist who works with pulmonary hypertension patients, I am often asked which over the counter (OTC) medications are safe for patients to take. Over the counter medications should be used cautiously in patients with pulmonary hypertension. Many of these medications have the potential to adversely affect the heart and lungs, or to interact with pulmonary hypertension medications.
Any drug that is contraindicated in patients with high blood pressure should be avoided in patients with pulmonary hypertension.1 Decongestants cause vasoconstriction (narrowing) of the blood vessels, which can increase blood pressure and heart rate, and may worsen pulmonary hypertension symptoms. They are found in various OTC medications marketed for flu, cold, sinus, allergy or headache. Some examples of oral decongestants are pseudoephedrine (Sudafed™, NeoCitran™), or phenylephrine (Sudafed PE™, Dristan™, NeoCitran™). Some examples of nasal decongestants are oxymetazoline (Dristan™, Dristoral™), phenylephrine (Neo Synephrine™), or xylometazoline (Otrivin™). These are just a few name brands - be sure to check with your pharmacist or carefully read the product label as there are many more.
The Non-steroidal anti-inflammatory drugs (NSAIDS) are a class of medications used to treat a variety of conditions and are available both by prescription and OTC.  Ibuprofen (marketed under the trade names Motrin™ or Advil™), ASA (Aspirin™, Anacin™) and naproxen (Aleve™) are a few examples available OTC in Canada. These ingredients are typically used to relieve pain and inflammation, but they are often found in cold or sinus medications. NSAIDs may promote sodium and water retention, which may result in an increased blood pressure and/or an exacerbation in congestive heart failure.2 Furthermore, this class of medications may increase the risk of bleeding when taken concurrently with warfarin (Coumadin™). Medications in the NSAID family should be used with caution and only under the advice of a physician.
 Acetaminophen (Tylenol™) is another analgesic, unrelated to the NSAID family. It appears to be safer in patients taking warfarin; although large doses have been found to interact with warfarin and increase the risk of bleeding.3 Large doses of acetaminophen also have the potential to cause liver damage. It is currently not known whether acetaminophen taken in combination with bosentan (Tracleer™) or ambrisentan (Volibris™) could increase the risk of liver damage in patients with pulmonary hypertension1.
Caffeine is a stimulant which is sometimes found in a variety of OTC medications for headache or menstrual cramps (Midol™, Excedrin™). Over the counter medications containing caffeine should be avoided, as in large doses they may increase blood pressure, or cause palpitations or an abnormal heart rhythm.
Ingredients that possess stimulant-like properties have also been found in many herbal products. (Ma huang). Unfortunately, there is often a lack of scientific data regarding the safety and efficacy of most herbal products. Herbal products have adverse effects similar to conventional medications and may adversely affect the heart, lungs or liver. Many herbal products have been found to interact with medications commonly used in pulmonary hypertension, such as warfarin, digoxin, or calcium channel blockers. Even though a product is touted as natural, it should not be assumed to be safe.1 Herbal products should therefore be avoided unless approved by your pulmonary hypertension specialist.
When choosing an OTC product, always be sure to read the product label paying special attention to the active ingredient section. Selecting an OTC medication can be confusing. Familiar brands often market multiple products, each potentially containing different ingredients. For example, Robitussin DM™ contains the active ingredients guafenesin and dextromethorphan, while Robitussin Cough and Cold™ additionally contains pseudoephedrine. The latter product therefore should be avoided in patients with pulmonary hypertension. If you are unsure which products are safe, be sure to check with your pulmonary hypertension team. Your pharmacist will also be an excellent resource to help navigate the way through the often overwhelming multitude of choices in a pharmacy’s OTC section.
While this article addresses the safety of OTC medications in pulmonary hypertension, it is also important to remember other individual disease considerations. Certain OTC medications should be avoided in conditions such as diabetes, glaucoma or asthma, and may interact with other classes of medications. It is also important to consider individual dietary considerations. Patients on a low salt diet will want to consider the sodium content of the chosen product. A sodium-restricted diet (less than 2400mg/d) is generally recommended for all pulmonary hypertension patients4, while other patients may be on a more severely restricted diet. Likewise, individuals with diabetes should consider the sugar content when choosing an OTC product.
In conclusion, caution should be used when choosing an OTC product for the patient with pulmonary hypertension. Certain drug classes such as decongestants and NSAIDS, as well as herbal products, may cause harm and generally should be avoided. Also, individual disease and dietary considerations should be taken into account. Careful reading of labels is advised for safe selection of products, and when in doubt, consult with your healthcare provider.