During bouts of hypotension, some physicians may be reluctant to continue prescribing olmesartan (Benicar), a medication which is otherwise used to reduce blood pressure. But, it is important that they do. Olmesartan has an excellent safety profile and is only a weak hypotensive, reducing diastolic pressure by no more than 12 mm Hg in the dosages suggested by the Marshall Protocol guidelines.
Patients and their physicians are advised not to be overly concerned with symptoms of low blood pressure. They resolve as the disease does. Also, the symptoms thought to be due to low blood pressure have been shown to resolve even if the low blood pressure persists.
The NIH has created no medical standards that define low blood pressure, or a range in which low blood pressure is considered dangerous. In 2004, the NIH issued blood pressure guidelines for clinical practice. While three levels of hypertension are listed, these guidelines do not single out any range of blood pressures as being low or abnormally low – only blood presssures below 120/80 are considered to be normal.
We really don't consider blood pressure to be low unless the pressure will not support the person when (s)he goes from laying to sitting to standing. If (s)he can do that without blacking out, the pressure is fine.
Madwolf, PA, MarshallProtocol.com
Further, there is no proof that the values normally used to indicate low blood pressure in healthy patients have any relevance to Th1 inflammatory disease patients. Symptoms which appear to be caused by hypotension – dizziness, fatigue, lightheadedness – are a result of the disease and will resolve as the inflammation resolves no matter the number of the blood pressure.
Therefore, it is not necessary to monitor blood pressure while on the MP. Some MP physicians do not recommend blood pressure checks. They simply tell their patients to lie down if they feel dizzy. Even patients with extremely low blood pressure – 85/55 or lower – have been able to continue taking olmesartan (Benicar).
As it is otherwise used, the primary indication for olmesartan (Benicar) is as a mild hypotensive drug. As one can see from the FDA label for Benicar, the dose response curve for Benicar follows a horizontal parabola, with additional doses of the drug having incrementally smaller decreases in blood pressure. For example, the difference between 40mg and 80mg of olmesartan results in an increase of no more than 1mm Hg. This chart is for a single dose given at one time and does not account for a patient taking four doses over 24 hours nor does it show how doses of 160mg affect blood pressure. However, given the clarity of this trend, it is reasonable to assume that the additional effect on blood pressure of 160mg as compared to 80mg of olmesartan, at least when it comes to blood pressure, is limited.
It is important to understand that olmesartan’s effect on blood pressure is limited in order to appreciate that a decline in systolic pressure greater than 15mm Hg of mercury is not due to Benicar’s hypotensive action.
One such factor is the effect the widespread destruction of bacteria and human cells infected by bacteria can have on blood pressure. Though this isn’t true of all bacterial forms, when some forms of bacteria are destroyed, they release endotoxins,1 the bioavailability of which can lead to a steep decline in blood pressure.2 For example, one lab worker ingested very large amounts of salmonella endotoxin (much more than could ever be generated by an MP patient) and found his blood pressure drop to 42/20 mm Hg.3
Olmesartan has an excellent safety profile.
When we visited the US FDA in Washington in April 2007, we were told that “Benicar is the safest drug in the US formulary.” I am at a loss to understand what the “side effects of Benicar” might be. I have been looking for them for six years, and all I can find is epidemic Th1 disease, and a consequent reaction to Benicar when patients' immune systems are activated to recognize the pathogens.
If blood pressure becomes too low, it is as a result of the disease, the immunopathology, as the drug doesn't have much pressor effect in healthy people (max 12 mm Hg).
Trevor Marshall, PhD
Blood pressure fluctations are due to the inflammatory disease not Benicar. Reducing the dose will eliminate the inflammatory blockade and make the situation worse.
Typically, patients taking olmesartan do not have any problem with hyponatremia (low sodium). It would be incorrect to assume that one's sodium is low just because one's blood pressure is low. Concerned patients can ask their physician to test their sodium level.
Gatorade and other energy replacement drinks are not recommended. Even those which are low in sugar contain extra potassium which you may not need. However, these drinks may be helpful if a patient has chronic diarrhea or experiences a lengthy bout of severe diarrhea.
Certain symptoms associated with low blood pressure – dizziness, vertigo, and fainting – are not caused by low blood pressure, but coincidental to it.
Many MP patients report symptoms of dizziness in the first week or weeks after taking olmesartan. This is due to initial hormonal fluctuations. For example, levels of 1,25-D sometimes fall by as much as 50% during this time.
Later on, during the treatment itself, low blood pressure is thought to be caused by the release of endotoxins during bacterial die-off, a necessary part of immunopathology. This totally upsets the body's hormonal balances. The readjustment process can cause symptoms such as vertigo and dizziness, which are from the disease – not from the lower blood pressure.
As the inflammation resolves with the MP, dizziness resolves also. The dizziness resolves even when the blood pressure remains low and the dosage of Benicar remains the same.
Vertigo, a type of dizziness, refers to the sensation of spinning or whirling that occurs as a result of a disturbance in balance (equilibrium). It also may be used to describe feelings of dizziness, lightheadedness, faintness, and unsteadiness. The sensation of movement is called subjective vertigo and the perception of movement in surrounding objects is called objective vertigo.
Vertigo usually occurs as a result of a disorder in the vestibular system – that is, structures of the inner ear, the vestibular nerve, brainstem, and cerebellum. The vestibular system is responsible for integrating sensory stimuli and movement and for keeping objects in visual focus as the body moves.
Vestibular rehabilitation therapy (VRT) is a type of physical therapy used to treat vertigo. In VRT, the patient performs exercises designed to allow the brain to adapt to and compensate for whatever is causing the vertigo.
Benign paroxysmal positional vertigo may be treated with meclizine (Antivert), an oral antiemetic that can be taken up to three times a day, or only as needed. Meclizine may cause drowsiness, dry mouth, and blurred vision.
Fainting (syncope) is a transient loss of consciousness with an inability to remain upright that is followed by spontaneous recovery. The term syncope excludes seizures, coma, shock, or other states of altered consciousness. Cardiac causes should be ruled out when a syncopal episode occurs.
Fainting may be due to neurological immunopathology.
With regards to “fainting” episodes, it has been my observation of my own response and my patients that there are 2 different conditions. One is almost always postural and is benign. Being attentive to the possibility of fainting with change of position plus insuring adequate hydration and some salt intake is usually all that is necessary….
The other, in my opinion, is a mild seizure disorder due to neurological Herx reaction. This causes “blacking out” which does not require postural change, is usually associated with some form of aura, and causes a transient loss of consciousness. This, I believe, is due to glial cell apoptosis (die off) and subsequent transient dysruption of neuron function. If spells are frequent or severe, an anti-epileptic, such as gabapentin (Neurontin), may be necessary.
Besides myself, I have had several patients who have “blacked out.” These were not because of low blood pressure but were, I believe, a neurological event. It tends to occur in people with pre-existing neurological symptoms such as tinnitus, visual disturbance or paraesthesia. I found increasing hydration afterwards lessens after effects.
It also tends to become less frequent as one progresses and decreases the bacterial load. IMO, it is a Herx reaction affecting the electrical functioning of the brain, similar to the symptoms seen in the heart where conduction abnormalities are common in Th1 disease.
Greg Blaney, MD
It isn't necessary to force someone to wake up following fainting. Tell your family to make sure you are breathing and call for emergency assistance only if you do not arouse with normal stimulation of movement and noise, in a couple minutes.
I checked my blood pressure for the first time for months the other day and was surprised to find it at 87/55, and I am not having dizzy spells as I was early in the Protocol when my blood pressure was low. I assumed my blood pressure was back to 120/80 or something considered more the norm. It was a pleasant surprise to find my blood pressure so low and my condition improving.
When I started Benicar and became dizzy, I assumed it was my very low blood pressure. Trevor told me it was the disease causing the dizziness. I didn't believe him until months later when the dizziness had gradually subsided. I did notice once when I was hypovolemic that the dizziness was worse. But drinking enough fluids and getting enough salt in my diet is not a problem. I'm still taking Benicar every six hours and my blood pressure is usually 75/55 on a busy day. I experience very transient dizziness rarely now which I attribute to the immunopathology. Surely if it were my low blood pressure, I would be dizzy all the time.
My B/P in the middle of a busy workday is routinely 75/45. I have no symptoms related to this low blood pressure. I had some lightheadedness in the early days of the MP which gradually resolved as my inflammation resolved. I suspect that when Th1 inflammation is conquered, the medical community will have to redefine normal blood pressure.
Taking less Benicar, as I know from experience, will only make you feel worse, but will not have any effect on the low numbers. One day, I took less, felt worse, and my BP was even lower than it was on the correct MP dosage! When my doctor realized that, she allowed me to take my Benicar as recommended, and with time, things settled down very well and she (and I) stopped worrying about low BP altogether. These day, four months into the MP, I still have some really low BP (around 75/45), but, ironically often feel much better then than I do at higher readings, which goes to prove that the Benicar is not causing your problem, but the disease process is. At my last doctor visit, I had a BP reading of 100/70, which is the highest I have ever been - even not on Benicar, and that day, I had taken it every 6 hours. Today, I am back to 76/46, and feel just fine there.
Even with my low BP, I have never passed out, I am able to lead a full life within the MP parmeters, and work as a teacher. I keep a bottle of water with me at all times, as the more hydrated I remain, the more stable my BP is, even if it is very low. If I feel bad during my working day, I take an extra 20 mg of Benicar, my BP goes up and I feel heaps better.
Have been to have my kidney function and BP checked and everything is much improved! Having increased my Benicar frequency to 6-hourly my blood pressure has risen to a respectable 94/57. This is remarkable, as it had stabilized at 80/40 since I was in Phase 1. So this is a lesson to others whose doctors panic and say “Whoa, your BP is dropping, you should take less of that Benicar.” The counter-intuitive answer is to TAKE MORE instead.
Hypovolemia - low blood volume can be caused by dehydration. Study found it to be extremely common in CFS. PMID 19469714: Chronic fatigue syndrome: Illness severity, sedentary lifestyle, blood volume and evidence of diminished cardiac function - Source: Clinical Science (Lond), May 2009.