Which medication is MOST associated with orthostatic hypotension in a dental patient?

Correct answer: A. Amitriptyline

• A. CORRECT. AMITRIPTYLINE is a tricyclic antidepressant with pronounced ALPHA-1 ADRENERGIC BLOCKADE, which prevents the reflex vasoconstriction that normally maintains blood pressure on standing. It also has strong ANTICHOLINERGIC effects (severe xerostomia, blurred vision, constipation) and, importantly for dentistry, it potentiates the cardiovascular effects of EPINEPHRINE — limit vasoconstrictor dose and avoid retraction cord containing epinephrine.
• B. Levothyroxine at appropriate dose has no hypotensive effect; overdose causes tachycardia and hypertension.
• C. Lisinopril can cause hypotension, but ACE inhibitors are less associated with classic postural drops than alpha-blocking agents; their signature effects are dry cough and angioedema.
• D. Metformin does not affect blood pressure or postural regulation.

Note: TCA patients: raise the chair slowly, expect severe dry mouth, and use epinephrine sparingly.