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Hypertension is nothing to sneeze at
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A 38-year-old male presented for follow-up of hypogonadism. The patient and his wife had a daughter of 13 months and were getting ready to try for a second child.
He had originally been diagnosed with cryptogenic hypogonadotrophic hypogonadism as part of an infertility workup and was found to have low semen volume and a low total serum testosterone level of <100 ng/dL. Pituitary workup had been negative.
The patient has been taking clomiphene 25 mg daily and has been tolerating medication well for the past year or so. He is describing better performance with exercise and is feeling a bit more emotional than he used to. Libido has improved, but despite recent improvement, he continued to report mild erectile dysfunction.
Other medical history consisted of childhood asthma and seasonal allergic rhinitis, which he had recently started treating with a daily dose of a store-brand formulation of cetirizine, an over-the-counter antihistamine.
Ronald Tamler
Other medications include calcium carbonate with vitamin D3 600 mg twice daily by mouth; mometasone (Nasonex, Schering Plough) into nostrils daily; and vardenafil (Levitra, Bayer) one 20-mg tablet by mouth as needed for relations.
Family history is remarkable for hypertension in the patient’s father.
On physical exam, I encountered a well-appearing man with a blood pressure of 150 mm Hg/90 mm Hg (confirmed when repeated by me), heart rate 100, height 5’10”, weight 86 kg (190 lb) and BMI of 27 kg/m2. The exam was otherwise unremarkable.
Morning labs showed good response to clomiphene, with a total testosterone of 450 ng/dL, estradiol of 22 ng/dL, normal comprehensive metabolic profile and CBC.
The patient had never had elevated BP before and was surprised to hear about it. I asked him to have it re-measured at a pharmacy the next day and call me in the office — it was still 150 mm Hg/90 mm Hg.
Case Discussion
Which of these options is the next best step in the management of this patient?
- A. Stop clomiphene immediately.
- B. Ask the patient to call and read you the exact name and ingredients of the antihistamine.
- C. Ask the patient to stop having relations with his wife because the excitement and the vardenafil are exacerbating his hypertension.
- D. Start atenolol 25 mg daily.
Answer: B
This patient had come to see me for his hypogonadotrophic, or secondary, hypogonadism. Although testosterone supplementation is a widely available and proven FDA-approved treatment for hypogonadism, it is also likely to suppress semen production. One possible treatment in this situation is, therefore, the use of the selective estrogen receptor modulator (SERM) clomiphene at a low dose to stimulate testosterone production. Although this treatment has been reported in men for decades, it is not FDA-approved in men. This patient had been taking clomiphene with good results for 2 years and had never had hypertension. I was therefore disinclined to stop the medication (A). Similarly, the man’s hypertension should not affect his relations with his wife, and if anything, vardenafil would decrease BP, albeit merely temporarily (C). His erectile dysfunction would not be well served by prescribing atenolol because beta-blockers are known to worsen erectile function. I did, however, have a hunch that the patient was taking an antihistamine that also contained pseudoephedrine (these formulations often carry a “D” at the end of the store name). An excellent decongestant, pseudoephedrine acts as an alpha agonist and may increase BP. I advised the patient to switch to cetirizine without pseudoephedrine. At his follow-up visit, his BP was 114 mm Hg/77 mm Hg, with a heart rate of 65.