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Vol 2 | Issue 2 | Apr – Jun 2023                                                                                     Indian J Pharm Drug Studies | 87  

Case Report 

A case report on tricyclic antidepressant induced increased blood pressure 

Janice Jacson Mandumpala  

From, Pharm D intern, Department of Pharmacy Practice, Nirmala College of Pharmacy, Muvattupuzha, Ernakulam, Kerala, India. 

Correspondence to: Janice Jacson Mandumpala, Pharm D intern, Department of Pharmacy Practice, Nirmala College of Pharmacy, 

Muvattupuzha, Kerala, India. Email: janice.jacson@gmail.com  

ABSTRACT 

This is a case of antidepressant-masked high blood pressure. Administration of tricyclic antidepressants that cause raised blood pressure 

becomes particularly important in resistant hypertension cases. In this case, we report a case of raised blood pressure despite multiple 

antihypertensives. The patient also presented with electrolyte imbalances also raising the suspicion of drug side effects due to 

unnecessary drugs administered. Therefore, arriving at a clinical decision with minimal side effects and focused treatments requires 

identifying every detail of the patient, including their medical and medication histories. 

Key words: Amitriptyline, Resistant Hypertension, Anti-Hypertensive, Electrolyte Imbalance 

esistant hypertension is defined as ‘an above goal 

blood pressure despite adherence to at least three 

antihypertensives one of which should be a diuretic’. 

Although dietary sodium restriction is an important 

aspect in the control of blood pressure. In the given case, a 

geriatric patient has presented with hyponatremia and an above 

goal blood pressure level [1]. While addressing hypertensive 

episodes among individuals on anti-depressants, it seems 

important to understand the rise in blood pressure due to 

antidepressant treatment. Antidepressants can cause variations 

in blood pressure through the adrenergic, cholinergic, 

serotonergic, histaminergic, and dopaminergic systems. 

Selective serotonin reuptake inhibitors have a mild effect on 

blood pressure and are considered relatively safe among the 

geriatric population. Other antidepressants, such as 

Venlafaxine, Bupropion, Nefazodone, Trazodone, and tricyclic 

antidepressants, are associated with a rise in blood pressure. 

Tricyclic antidepressants affect blood pressure levels by 

various mechanisms [2]. 

Amitriptyline is a tricyclic antidepressant with multiple side 

effects and is more prominent within the geriatric population. 

The common side effects of Amitriptyline are weight gain, 

generalised weakness, hypotension, sleepiness, alopecia, 

blurred vision, dry mouth, vomiting, constipation, diarrhoea, 

urinary retention, and dyscrasias. Hypertension is a rare side 

effect of Amitriptyline use, but it can occur. In the given case, 

the patient is already diagnosed with resistant hypertension, and 

introducing a molecule such as amitriptyline with the potential 

to cause blood pressure elevations makes the clinical situation 

even more challenging. It is proposed that amitriptyline works 

by blocking norepinephrine reuptake or increasing vascular 

reactivity [3]. Here we describe an elderly woman with resistant 

hypertension who received amitriptyline for depression and 

then developed high blood pressure. All procedures performed 

in the case report involving human participants were in 

accordance with the ethical standards of the institutional and/or 

national research committee and with the 1964 Helsinki 

Declaration and its later amendments or comparable ethical 

standards. Informed consent was obtained from the individual 

included in this case report. The participant has also consented 

to the submission of a case report to this journal.  

Clinical Case 

A 68 year old female was admitted at 8 pm to the General 

medicine department of a primary care hospital. The patient 

complained of abdominal bloating for the past few days. The 

past medical history of the patient included hypertension (since 

10 years), asthma (since 30 years) and depression. The patient's 

previous medication history included metoprolol succinate 

prolonged release tablet 50 mg (1-0-1), telmisartan 40 mg (1-0-

1), torsemide 5 mg (1-0-0), moxonidine 0.3 mg (1-0-1), 

cilnidipine 10 mg (0-0-1), amitriptyline 10 mg (0-0-1) and 

inhaler formoterol fumarate 6 mcg and budesonide 200 mcg (2 

puffs). The patient also underwent a hysterectomy and 

hemorrhoidectomy ten years ago. The patient was also 

previously admitted with hyponatremia and hypokalemia 

following usage of Tablet Chlorthalidone 6.25 mg (1-0-1), 

which was subsequently discontinued and replaced with Tablet 

Torsemide 5 mg (1-0-0). After examination of the lab reports 

on Day 1 it was found that the sodium and potassium levels 

were 128 mEq/l and 3.3 mEq/l, respectively. The erythrocyte 

sedimentation rate (ESR) was elevated with a value of 38 

mm/hr. Likewise, the haemoglobin (Hb) level was 10.4 g/dL. 

Urine albumin was nil, sugar was nil, pus cells were 1-2; and 

RBCs in urine were 2-4. On admission, the patient had a blood 

pressure (BP) of 170/80 mm Hg. The BP monitoring chart has 

been tabulated in Table 1 below. 

R 

mailto:janice.jacson@gmail.com


Mandumpala                                                                                                    Amitriptyline induced high blood pressure 

Vol 2 | Issue 2 | Apr – Jun 2023                                                                                     Indian J Pharm Drug Studies | 88  

Table 1 – BP Monitoring Chart of the Patient during the Hospital stay and other lab investigations 

BP MONITORING CHART 

Day 1 Day 2 Day 3 

8pm 170/80* 

6am 

10am 

1pm 

6pm 

9pm 

120/70 

130/80 

120/70 

130/70 

160/90 

6am 130/70 

LAB INVESTIGATIONS 

Parameters Day 1 Day 3 

Hb (g%) 10.4  

ESR (mm/hr) 38  

Neutrophils (%) 52%  

Lymphocytes (%) 43%  

Eosinophils (%) 5%  

Sodium (mEq/l) 128 135 

Potassium (mEq/l) 3.3 4.4 

  

*All the BP measurements are in mm/Hg 

On admission, the patient was started on tablet amlodipine 5mg 

to quickly control the elevated BP level. The following day, the 

patient was instructed to take Tablet Tolvaptan 30 mg once 

daily (1-0-0) for sodium correction, Syrup potassium chloride 

2 tablespoons thrice daily (1-1-1) for potassium correction, and 

all previous medications (Metoprolol succinate prolonged 

release tablet 50mg (1-0-1), Tablet Telmisartan 40 mg (1-0-1), 

Tablet Moxonidine 0.3mg (1-0-1), Tablet Cilnidipine 10mg (0-

0-1),The BP measurements were regularly monitored, and 

another routine lab investigation was conducted to examine the 

electrolyte level. The values have been indicated in Table 1. 

The patient was diagnosed with resistant hypertension with 

hyponatremia and hypokalemia. A suspicion of acute gastritis 

was also raised, for which the patient was advised to take a 

syrup containing a combination of magaldrate (400 mg/5 ml) 

and simethicone (20 mg/5 ml) thrice daily (1-1-1). Complaints 

of bloating resolved post-consumption of the Syrup. Upon 

clinical improvement, the patient was discharged with the 

following list of medications: – tablet tolvaptan (30 mg 1-0-0 * 

4 days), tablet pantoprazole (40 mg 1-0-0*10 days), tablet 

amitriptyline (10 mg 0-0-1*15 days), tablet metoprolol 

succinate (50 mg 1-0-1 *continue), tablet telmisartan (40 mg 1-

0-1 *continue), tablet moxonidine (0.3 mg 1-0-1 *continue), 

and tablet cilnidipine (10 mg 0-0-1*continue). On follow up 

after 15 days, the patient had an in-office BP of 160/90 mm Hg. 

Following further investigation, it was determined that Tablet 

Amitriptyline 10 mg (0-1) could have resulted in increased 

blood pressure levels. Amitriptyline is a Tricyclic 

antidepressant and has the potential to cause elevations in BP. 

During follow-up, tablet amitriptyline 10 mg 0-0-1 was 

discontinued and tablet etizolam 0.25 mg 0-0-1 was added to 

overcome generalised anxiety and depressive symptoms. 

DISCUSSION 

This study highlights the effect of antidepressants in the context 

of resistant hypertension. Often, resistant hypertension is 

labelled based on the number of antihypertensives prescribed 

and the corresponding uncontrolled blood pressure levels. 

Upon further examination, such as a postmenopausal woman, 

suggesting the involvement of sex hormones there's a chance of 

getting higher BP (2), other factors that can lead to an increased 

level of blood pressure should be investigated. Otherwise, this 

could result in unnecessary treatment, charges, electrolyte 

imbalances, and other adverse drug reactions. 

In a study conducted by Breeden et al., the author has 

highlighted the role of antidepressants in elevating the chances 

of incident hypertension. Tricyclic antidepressants, in 

particular, have been linked to an increase in blood pressure. It 

is also argued that this class of antidepressants also causes 

orthostatic hypotension [4]. Therefore, large scale studies are 

necessary to validate the findings obtained from an individual 

patient. This case also highlights the need to promptly capture 

the instances of electrolyte imbalance among hypertensive 

patients. Therefore, if there is no need for anti-hypertensive 

such as this case where possibly amitriptyline could have 

caused the raised blood pressure, the patient is exposed to a 

drug with no indication. Tricyclic antidepressants are not only 

used for depression but also for anxiety, chronic pain, insomnia, 

and migraine. There are multiple sections of the population that 

are exposed to the threat of tricyclic antidepressants. A 

thorough understanding of the risks and benefits of medication 

prescribed for each patient can help improve the clinical 

decision making process. Although a nonjudgmental approach 

was used during the medication reconciliation process, it was 

difficult to determine whether the patient was truly adhering to 

the antihypertensive medications prescribed. A formal 

assessment of medication adherence to the existing anti-

hypertensives was not done; therefore, a conclusive diagnosis 

of resistant hypertension may be doubtful. Increasing age is 

also a factor that can make an individual resistant to treatment; 

thus, it cannot be ruled out in this case. 

CONCLUSION 



Mandumpala                                                                                                    Amitriptyline induced high blood pressure 

Vol 2 | Issue 2 | Apr – Jun 2023                                                                                     Indian J Pharm Drug Studies | 89  

This case highlights a common clinical situation where multiple 

causes of a complaint can remain masked or unnoticed. In this 

case, a geriatric patient arrives with elevated blood pressure 

despite prompt treatment, but the condition remains 

unresolved. Amitriptyline-induced hypertension could be one 

explanation. Such scenarios must be highlighted in practice for 

better patient outcomes. 

REFERENCES  

1. Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: 

Detection, evaluation, and management a scientific statement from 

the American Heart Association. Hypertension. 2018; 72(5): 53-

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2. Calvi A, Fischetti I, Verzicco I, et al. Antidepressant Drugs   

Effects on Blood Pressure. FCM. 2021;8:704281.. 

3. Hmoud M, Al-Husayni F, Alzahrani A, et al. Hypertension 

Secondary to Amitriptyline Use as Prophylactic for Migraine in a 

26-Year-Old Man. Cureus. 2021; 13(1):e12848.  

4. Breeden M, Brieler J, Salas J, et al. Antidepressants and Incident 

Hypertension in Primary Care Patients. JABFM. 2018;31(1):22-28. 
 

How to cite this article: Mandumpala J J. A case report on 

tricyclic antidepressant induced increased blood pressure. 

Indian J Pharm Drug Studies. 2023: 2(2) 87-89. 

Funding: None                    Conflict of Interest: None Stated 

 

 

 

 


