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Diphenhydramine
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Ibuprofen
Lisinopril
Metformin
Prazosin
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This patient who presents with orthostatic hypertension (feeling lightheaded when rising from seated to standing) in the setting of starting a new drug is probably experiencing orthostatic hypertension from taking his first dose ever of the alpha-adrenergic inhibitor prazosin. Alpha-adrenergic receptors are used by the sympathetic nervous system and can be modulated by 3 classes of drugs: non-selective alpha-adrenergic antagonists, selective alpha-1-adrenergic antagonists, and selective alpha-2-adrenergic antagonists. Non-selective blockers such as phentolamine are used in pheochromocytoma and can cause orthostatic hypotension as well as reflex tachycardia. Selective alpha-1 antagonists such as prazosin are used for urinary retention in benign prostatic hyperplasia and can cause headache as well as first-dose orthostatic hypotension. Finally, selective alpha-2 antagonists such as mirtazapine can be used for depression and can cause xerostomia. Poon and Braun studied geriatric patients who experienced orthostatic hypotension in elderly veterans and found that many medications including alpha-1-adrenergic blockers were associated with this symptom. Incorrect Answers: Answer 1: Diphenhydramine is a first-generation antihistamine commonly used over the counter for allergies and can cause sedation in elderly patients. These patients would present with confusion, fatigue, or delirium in extreme cases. Answer 2: Ibuprofen is commonly used for pain relief in patients with arthritis. Side effects can include gastric ulcers, renal dysfunction, esophagitis, and bleeding. Answer 3: Lisinopril is commonly used in the treatment of hypertension. Side effects most commonly include cough but may also include angioedema, hyperkalemia, and metabolic acidosis. Answer 4: Metformin is commonly used in the treatment of diabetes. Side effects include gastrointestinal symptoms such as diarrhea as well as lactic acidosis, but this is relatively rare. Bullet Summary: Alpha-1-adrenergic blockers such as prazosin can cause first dose orthostatic hypotension.
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