Managing Hypertension and Kidney Health: Concerns with Pain Medication

Q: Managing Hypertension and Kidney Health: Concerns with Pain Medication

Hello： Coxib medications belong to the new generation of non-steroidal anti-inflammatory drugs (NSAIDs), which are commonly used by physicians for their effective pain relief. <br>Compared to traditional NSAIDs, Coxib drugs have a lower incidence of side effects such as gastric u

Hypertension and Medication Issues

Dear Dr.
Huang,
I would like to ask you about my father, who is 70 years old and has been taking medication for hypertension and diabetes for many years.
His antihypertensive medication is "Dopamine," taken once daily.
He has always measured his blood pressure in the morning after waking up, before taking his medication.
However, in the past six months, I have noticed that his blood pressure has been unstable.
From December of last year to April of this year, he had at least 15 days each month with a systolic blood pressure above 140, occasionally reaching 150/90.
I have been trying to find out the reason for this instability over the past six months.
I traced back to September of last year when he started visiting an orthopedic clinic for knee joint degeneration.
The doctor prescribed "Celecoxib," which is a type of Coxib analgesic.
After reviewing the medication guide, I found that for patients with mild renal impairment, with a creatinine clearance of ≥30 mL/min, no dose adjustment is necessary.
However, it also states that it is contraindicated for individuals with persistent blood pressure of 140/90 or higher, which suggests it may not be suitable for him.
Currently, my father is taking Celecoxib at a dose of 60 mg once daily.
He has regular blood tests every three months.
In April, his creatinine level was 1.34 mg/dL, with a glomerular filtration rate (GFR) of 56.0.
In July, his creatinine increased to 1.46 mg/dL, and his GFR decreased to 50.7, which is below 60.
He has been taking this medication since September of last year.

I would like to ask you, Dr.
Huang, given his elevated blood pressure readings over the past six months and his kidney function results, could Celecoxib be affecting my father's hypertension and renal function? His urine test in April showed microalbumin at 898.2 mg/L and an ACR of 719.1 mg/g, both of which are elevated and have consistently exceeded normal values.
I am unsure which stage of chronic kidney disease he may be in.
Given his condition, can he continue taking Celecoxib?
Additionally, I have a question regarding the timing of his blood pressure measurements.
Since he is a person who tends to be in a hurry in the mornings, starting in June, he changed the time he measures his blood pressure to around 8 or 8:30 PM, after he returns home and takes his antihypertensive medication.
He measures his blood pressure around 10:30 or 11 PM, and recently, his readings have been maintained below 140/90.
He typically does not measure his blood pressure before bed but does so around 4:30 PM, which has also been normal.
Lastly, I would like to ask if it is acceptable for him to have normal blood pressure readings after taking his medication, or should blood pressure be measured before taking the medication for accuracy? Also, can my father continue taking Celecoxib? I have been reminding him to drink plenty of water after taking his medication, as it is beneficial for renal excretion.
Additionally, he should only take the pain medication when his knee discomfort arises or perhaps every other day, as long-term use of analgesics can burden the body.
We cannot simply take medication without consideration, as it may harm his renal function.
Thank you very much for your time and assistance, Dr.
Huang.
I wish you peace and happiness.

TK55, 40~49 year old female. Ask Date: 2021/07/11

Dr. Huang Yinghe reply Cardiology

Hello: Coxib medications belong to the new generation of non-steroidal anti-inflammatory drugs (NSAIDs), which are commonly used by physicians for their effective pain relief.
Compared to traditional NSAIDs, Coxib drugs have a lower incidence of side effects such as gastric ulcers and gastrointestinal bleeding.
There are no specific contraindications for patients with high blood pressure.
However, caution is advised for patients with impaired kidney function, as long-term use may indeed lead to worsening renal function.

Sometimes, when joint pain becomes unbearable without pain relief, it is important to inform the orthopedic physician about any deterioration in kidney function when selecting pain medications, and to consider alternative options.
There are many causes of worsening kidney function; pain medications are one possibility, while others include insufficient fluid intake, urinary obstruction (such as stones or benign prostatic hyperplasia), infections, and long-term hypertension or diabetes.
Some elderly individuals may drink less water to avoid frequent bathroom trips, which can be detrimental to kidney health.
Your father's urine protein levels are elevated, and his estimated glomerular filtration rate (eGFR) has declined, indicating stage 3 chronic kidney disease (eGFR 59-30; stage 5 is the most severe, requiring dialysis when eGFR is less than 15).
As blood pressure increases, the rate of kidney function deterioration also accelerates, and poorer kidney function often makes blood pressure more difficult to control.
Therefore, managing blood pressure is crucial for maintaining kidney function.
Current consensus on the treatment of chronic kidney disease suggests keeping blood pressure below 130/80 mmHg.
There are standard practices for measuring blood pressure.
It is best to measure it at home when fully rested and calm.
I recommend my patients measure and record their blood pressure in the morning after waking up and before going to bed at night.
If these times are inconvenient, choosing a fixed time during the day is also acceptable.
The recorded blood pressure can then be provided to the physician during outpatient visits to guide medication adjustments.
If blood pressure readings are mostly within the target range, that is sufficient; the goal of medication is to achieve target blood pressure values, which helps reduce the incidence and worsening of cardiovascular and kidney diseases.
In summary, due to the recent signs of worsening kidney function in your father, I recommend discussing with the orthopedic physician whether to switch to other pain medications or to reduce the frequency of pain medication use.
Please also coordinate with the physician managing his hypertension and diabetes for blood pressure control, as well as blood sugar management, which are both important for kidney function.
Wishing you good health, Dr.
Huang Ying-He, Cardiology Department, Chiayi Hospital.

Reply Date: 2021/07/11

More Info

Managing hypertension, especially in older adults with coexisting health conditions, requires careful consideration of medication interactions and side effects. In your father's case, it appears that he has been experiencing fluctuating blood pressure readings and has been prescribed "道脈樂" (likely a brand name for a common antihypertensive medication) along with "萬克適" (a Coxib class pain medication) for knee pain due to osteoarthritis.

Understanding the Medications
1. Coxibs and Kidney Function: Coxibs, such as "萬克適," are non-steroidal anti-inflammatory drugs (NSAIDs) that are often used for pain relief. While they are generally easier on the stomach compared to traditional NSAIDs, they can still pose risks to kidney function, especially in patients with pre-existing kidney issues or those who are elderly. Your father's kidney function has been declining, as indicated by the decrease in his glomerular filtration rate (GFR) from 56.0 to 50.7 mL/min over a few months. This decline is concerning and suggests that the use of Coxibs may need to be re-evaluated.

2. Blood Pressure Concerns: The use of NSAIDs, including Coxibs, can lead to fluid retention and increased blood pressure, which may explain the elevated readings you have observed. The fact that your father has had multiple days with systolic readings above 140 mmHg indicates that his blood pressure is not well controlled, which is critical to address, especially given his kidney health.

Assessing Kidney Function
Based on the information provided, your father's urine tests show elevated protein levels, which can indicate kidney damage. The presence of microalbuminuria (898.2 mg/L) and an ACR (Albumin-to-Creatinine Ratio) of 719.1 mg/g suggest that he may be experiencing early stages of chronic kidney disease (CKD). Given his GFR of 50.7, he is likely in stage 3 CKD, which requires careful management to prevent further decline.

Recommendations
1. Medication Review: It is crucial to discuss with your father's healthcare provider the ongoing use of "萬克適." Given his declining kidney function and fluctuating blood pressure, it may be advisable to consider alternative pain management strategies that are less likely to impact his blood pressure and kidney health. Options may include acetaminophen or topical NSAIDs, which might provide relief without the systemic effects of oral medications.

2. Blood Pressure Monitoring: The timing of blood pressure measurements can significantly affect the readings. It is generally recommended to measure blood pressure at the same times each day, ideally in a calm state, to get the most accurate readings. Your father's practice of measuring his blood pressure after taking his medication is acceptable, but it is also beneficial to measure it before medication to assess the baseline pressure. Consistency in timing will help in understanding how well his medications are controlling his blood pressure.

3. Lifestyle Modifications: Encourage your father to maintain a heart-healthy lifestyle, which includes a balanced diet low in sodium, regular physical activity, and adequate hydration. Drinking enough water is particularly important for kidney health, especially when taking medications that may affect renal function.

4. Regular Follow-ups: Ensure that your father has regular follow-ups with his healthcare provider to monitor his blood pressure and kidney function closely. Adjustments to his treatment plan may be necessary based on his ongoing assessments.

Conclusion
In summary, your father's situation requires a comprehensive approach that includes medication management, lifestyle changes, and regular monitoring of both blood pressure and kidney function. Open communication with his healthcare provider is essential to ensure that his treatment plan is effective and safe. If there are any concerns about the medications or his health status, do not hesitate to seek a second opinion or further evaluation from a specialist, such as a nephrologist or a geriatrician.

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