People have been warned that salt (sodium chloride) is dangerous, especially for people with high blood pressure. But most people love the taste of standard salt. That’s why potato and tortilla chips are so popular. Americans spend over $3 billion in convenience stores on just those snacks. Not far behind are salty nuts, crackers and pretzels. People who cannot give up the taste of sodium chloride are often told to substitute potassium chloride as a salt substitute. It can help lower blood pressure. Learn more at this link. But extra potassium can pose an unexpected risk for some people. Physicians don’t always warn their patients about this risk, as this reader relates:
Potassium Chloride Can Sometimes Be Life Threatening:
Q. I have been taking lisinopril for years to control hypertension. It seems obvious that you should reduce salt. After all, salt can raise blood pressure.
I have learned from your column NOT to use salt substitutes. I am very surprised I needed to learn this from you because neither my pharmacy nor my doctor warned me about it.
A. Lisinopril is known as an ACE (angiotensin converting enzyme) inhibitor. Many blood pressure pills such as thiazide diuretics deplete the body of potassium. ACE inhibitors, on the other hand, help the body preserve potassium. Similar drugs include benazepril, captopril, enalapril, fosinopril, moexipril, perindopril and ramipril. When you see “pril,” think ACE inhibitor.
Using a potassium-based salt substitute while taking an ACEi could lead to an excess of this mineral. Too much potassium (hyperkalemia) is just as dangerous as too little (hypokalemia). Symptoms of hyperkalemia may include weakness, slow pulse, heart palpitations, tingling or numbness in hands, feet or lips and confusion. When potassium levels get too high, they can cause fatal heart rhythm abnormalities.
Another class of drugs that pose similar risks are ARBs (angiotensin receptor blockers) such as losartan. Similar drugs include candesartan, olmesartan, telmisartan and valsartan. When you see “sartan,” think ARB.
The Confusing Salt Story:
To make matters a bit more confusing, here is question from a reader about standard salt (sodium chloride).
Q. I recently was diagnosed with high blood pressure and advised to eliminate salt. My question to you: is salt substitute (potassium chloride) safe?
A. Ask your physician to review a study that was recently published in The Lancet (online, May 20, 2016). This research showed that a really low-salt diet may be counterproductive and increase the risk of cardiovascular complications (heart attacks, strokes, heart failure deaths). On the other hand, too much salt (over 6,000 mg daily) is also dangerous for people with hypertension.
Listen to the Lead Author Explain the Confusing Sodium Story:
We know this seems counterintuitive and you may not wish to wade through a lot of medical terminology. That’s why we interviewed the lead author, Andrew Mente, PhD, Associate Professor in the Department of Clinical Epidemiology & Biostatistics at McMaster University on our radio. You can listen to his 10-minute explanation of the results of this landmark study at this link.
The Topsy-Turvy World of Diuretics:
Please pay attention, this is really confusing!
Too Little Potassium (Hypokalemia)
Most diuretics deplete the body of potassium. Such drugs are swallowed by tens of millions of Americans every day. We are referring to drugs like:
Bendroflumethiazide (Naturetin)
Benzthiazide (Exna)
Bumetanide (Bumex)
Chlorothiazide (Diuril, Diachlor, Diurigen)
Chlorthalidone (Hygroton)
Ethacrynic acid (Edecrin)
Furosemide (Lasix)
Hydrochlorothiazide (Esidrix, HydroDIURIL, Oretic)
Hydroflumethiazide (Diucardin)
Methyclothiazide (Aquatensen, Enduron)
Polythiazide (Renese)
Trichlormethiazide (Diurese, Metahydrin, Naqua)
Such diuretics are also included in the formulas of many combination blood pressure pills. They flush potassium out of the body and often lead to hypokalemia.
When serum potassium drops below 3.5 mEq/L it can cause irregular pulse, muscle cramps, breathing difficulties and weakness.
Too Much Potassium (Hyperkalemia)
We promised confusion, so here goes. Although most diuretics deplete the body of potassium, there are some that actually help the body retain potassium. They include:
Potassium Sparing Diuretics:
- Eplerenone (Inspra)
- Spironolactone (Aldactone, Aldactazide)
- Triamterene (Dyrenium, Dyazide, Maxzide)
- Amiloride (Midamor, Moduretic)
When potassium-sparing diuretics are added to certain blood pressure medications, they can lead to a buildup of potassium. The same thing can occur when a salt substitute containing potassium chloride is added to such medications for hypertension.
These include ACE Inhibitors and ARBS:
ACE Inhibitors:
• Benazepril (Lotensin)
• Captopril (Capoten)
• Enalapril (Vasotec)
• Lisinopril (Prinivil, Zestril)
• Quinapril (Accupril)
• Ramipril (Altace)
ARBs (Angiotensin Receptor Blockers)
• Candesartan (Atacand)
• Irbesartan (Avapro)
• Losartan (Cozaar)
• Olmesartan (Benicar)
• Telmisartan (Micardis)
• Valsartan (Diovan)
The Dangers of Too Much Potassium (Hyperkalemia)
When potassium levels exceed 5 mEq/L the risk is hyperkalemia. This can be equally dangerous as too little potassium. Here are symptoms to be alert for:
Palpitations, heart rhythm changes
Tingling or numbness in lips, feet, or hands
Breathing difficulty
Weakness
Slow pulse
Confusion
The People’s Pharmacy Bottom Line on Potassium Chloride:
Salt substitutes containing potassium chloride are a reasonable option as long as you are not taking certain blood pressure pills that preserve potassium. Always check with your pharmacist and physician to make sure you do not end up with a drug interaction that could cause life-threatening irregular heart beats!
Here is a link to an article of similar interest: “A Deadly Interaction Often Ignored by Doctors and Pharmacists”
To learn more about the pros and cons of such drugs and other approaches for controlling hypertension, you may find our eGuide to Blood Pressure Solutions helpful. This online resource can be found under the Health eGuide tab at www.PeoplesPharmacy.com.
Please share your own experience with salt substitutes such as potassium chloride in the comment section below.
