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ALCOHOL + ANTIHYPERTENSIVES
Chronic moderate to heavy drinking raises the blood pressure and reduces, to
some extent, the effectiveness of antihypertensive drugs. A few patients may
experience postural hypotension, dizziness and fainting shortly after having drank
alcohol. Alpha blockers may enhance the hypotensive effect of alcohol in subjects
susceptible to the alcohol flush syndrome.
Clinical evidence, mechanism, importance and management.
(a) Hypertensive reaction
A study in 40 men with essential hypertension (taking beta blockers, captopril,
diuretics, methyldopa, prazosin or verapamil) who were moderate to heavy drinkers,
found that when they reduced their drinking over a 6-week period from an average of 450
mL of alcohol weekly (about 6 drinks daily) to 64 mL of alcohol weekly, their average blood
pressure fell by 5/3 mmHg.1 The reasons for this effect are uncertain.
The Atherosclerosis Risk in Communities (ARIC) study involving 8334 subjects who
were free from hypertension at baseline and were assessed after 6 years, found that higher
levels of consumption of alcoholic beverages (210 g or more of alcohol per week;
approximately 3 drinks or more per day) were associated with a higher risk of
hypertension. Low to moderate consumption of alcohol (up to 3 drinks/day) was
associated with an increase in blood pressure in black, but not in white men.2 A study in
Japanese men found that the effect of alcohol intake on the risk of developing hypertension
was dose-dependent, starting at low-to-moderate levels of alcohol (less than 23 g/day).
These findings are consistent with those of other studies in hypertensive4 and
normotensive5 subjects. It seems likely that this effect will occur with any
antihypertensive. Patients with hypertension who are moderate to heavy drinkers should
be encouraged to reduce their intake of alcohol. It may then become possible to reduce the
dosage of the antihypertensive. It should be noted that epidemiological studies show that
regular light to moderate alcohol consumption is associated with a lower risk of
cardiovascular disease.

Table 2.1 betablockers and diuretics

Group Drugs
Beta Blockers Acebutolol, Atenolol, Betaxolol, Bisoprolol, Metoprolol, Nadolol,
Nebivolol, Propanolol
Diuretics Spironolactone, Eplerenon, Triamterene, Amiloride
 (b) Hypotensive reaction
A few patients taking some antihypertensives feel dizzy or begin to ‘black out’ or faint if
they stand up quickly or after exercise. This orthostatic and exertional hypotension may be
exaggerated in some patients shortly after drinking alcohol, possibly because it can lower
the cardiac output (noted in patients with various types of heart disease7,8). For other
reports of postural hypotension with alcohol, see ‘alpha blockers’, (p.42), and ‘calcium
channel blockers’, (p.57). Some manufacturers of antihypertensives e.g. ACE inhibitors9,10
and thiazide diuretics11 warn that acute alcohol intake may enhance the hypotensive
effects, particularly at the start of treatment,10 and this could apply to any
antihypertensive. Patients just beginning antihypertensive treatment should be warned.

PREVENTION AND TREATMENT OF ALCOHOL-HYPERTENSION

Studies have shown that a reduction in alcohol intake is effective in lowering the blood
pressure both in hypertensives and normotensives and may help to prevent the
development of hypertension[12,41,95,96]. Heavy drinkers who cut back to moderate
drinking can lower their systolic blood pressure by 2 to 4 mm of mercury (mm Hg) and
their diastolic blood pressure by 1 to 2 mmHg. Heavy drinkers who want to lower blood
pressure should slowly reduce how much they drink over one to two weeks.
Another non-pharmacological prevention and treatment of alcohol-induced hypertension is
physical conditioning or exercise training. There is a physiological basis for effect of
physical conditioning on chronic alcohol-induced hypertension in a rat model. Exercise
increases the utilization of oxygen in the body and up-regulate the antioxidant defense
system in the cardiovascular system[97-100]. Exercise training also generates NO in the
cardiovascular system by induction of nitric oxide synthase[19,79,90,101]. Recent studies
have shown the beneficial role of physical training in the control of blood pressure in
humans[97,98,102,103] and experimental animals[79,90,104,105]. Physical inactivity and
overweight trigger hypertension[106,107] whereas; regular physical activity has been
shown to decrease the BP and body weight[102,103]. Studies have shown that physical
conditioning is beneficial in lowering the BP through suppression of weight gain in chronic
ethanol treated hypertensive rats[19,79]. Physical conditioning attenuates the chronic
ethanol-induced hypertension by augmenting the NO bioavailability and reducing the
oxidative stress response in rats[19,79,108]
(c) CNS and other effects
For mention of the possibility of increased sedation with alcohol and clonidine or
indoramin, see ‘Clonidine and related drugs + CNS depressants’, p.883 and ‘Alcohol + Alpha
blockers’, p.42. For the possible CNS effects of beta blockers and alcohol, see ‘Alcohol + Beta
blockers’, p.55. For mention of the disulfiram-like reaction
Reference :
1. Puddey IB, Beilin LJ, Vandongen R. Regular alcohol use raises blood pressure in treated
hypertensive subjects. A randomised controlled trial. Lancet (1987) i, 647–51.
2. Fuchs FD, Chambless LE, Whelton PK, Nieto FJ, Heiss G. Alcohol consumption and the
incidence of hypertension. The Atherosclerosis Risk in Communities Study. Hypertension
(2001) 37, 1242–50.
3. Nakanishi N, Yoshida H, Nakamura K, Suzuki K, Tatara K. Alcohol consumption and risk
for hypertension in middle-aged Japanese men. J Hypertens (2001) 19, 851–5.
4. Potter JF, Beevers DG. Pressor effect of alcohol in hypertension. Lancet (1984) i, 119–22.
5. Puddey IB, Beilin LJ, Vandongen R, Rouse IL, Rogers P. Evidence for a direct effect of
alcohol on blood pressure in normotensive men — a randomized controlled trial.
Hypertension (1985) 7, 707–13.
6. Sesso HD. Alcohol and cardiovascular health: recent findings. Am J Cardiovasc Drugs
(2001) 1, 167–72.
7. Gould L, Zahir M, DeMartino A, Gomprecht RF. Cardiac effects of a cocktail. JAMA (1971)
218, 1799–1802.
8. Conway N. Haemodynamic effects of ethyl alcohol in patients with coronary heart
disease. Br Heart J (1968) 30, 638–44.
9. Innovace (Enalapril). Merck Sharp & Dohme Ltd. UK Summary of product characteristics,
October 2005.
10. Capoten (Captopril). E. R. Squibb & Sons Ltd. UK Summary of product characteristics,
June 2005.
11. Moduret (Amiloride/Hydrochlorothiazide). Bristol-Myers Squibb Pharmaceuticals Ltd.
UK Summary of product characteristics, September 2006.