Corticosteroid-Induced Hypertension

Mechanism and Clinical Evidence

Systemic corticosteroids, including prednisone, are listed among medications that cause elevated blood pressure in the 2017 ACC/AHA Hypertension Guidelines, with mechanisms including mineralocorticoid-like effects, direct increase in cellular potassium efflux, and promotion of atherosclerosis, diabetes, and ischemic heart disease 1, 2, 3, 4, 5
The American College of Cardiology and American Heart Association recognize prednisone as a medication that elevates blood pressure, requiring avoidance or limitation when possible, with consideration of alternative routes of administration when feasible 1, 2, 3, 4

The American College of Cardiology recommends a hierarchical approach to managing corticosteroid-induced hypertension, including avoiding or limiting systemic corticosteroid use when possible, considering alternative routes of administration, and initiating or intensifying antihypertensive therapy if systemic use is necessary 1, 2, 3, 4
The American College of Cardiology suggests that blood pressure monitoring should be regular, even during short courses, with baseline blood pressure assessment before initiating therapy and frequent monitoring during dose changes 6, 7

Regular blood pressure monitoring is recommended, even during short courses, with a baseline blood pressure assessment before initiating therapy 6, 7
Serum glucose monitoring is also recommended, as hyperglycemia commonly occurs and may contribute to cardiovascular risk 6

The American Heart Association recommends using ACE inhibitors or ARBs as first-line agents for hypertension management in patients receiving systemic corticosteroids, due to their effectiveness in reducing cardiovascular events 8, 9, 10.
The American Diabetes Association suggests adding thiazide-like diuretics, such as chlorthalidone or indapamide, as second-line agents to reduce cardiovascular events 8, 9.
The American College of Cardiology recommends using dihydropyridine calcium channel blockers, such as amlodipine or nifedipine, as third-line therapy 8, 9.
For patients with resistant hypertension, the American Heart Association recommends adding spironolactone if serum potassium is <4.5 mmol/L and eGFR is >45 mL/min/1.73m², while monitoring potassium levels closely 11, 10.

The American Heart Association advises against combining ACE inhibitors with ARBs, as this increases adverse events without additional benefit 8.
The American College of Cardiology recommends avoiding the use of nondihydropyridine calcium channel blockers, such as verapamil or diltiazem, in patients with heart failure, as they are contraindicated 9, 10.