10/22 Flashcards
pharm therapy
1st line: thiazides, ACE/ARB/renin inhibitors, CCBs
2nd line: loops, K sparing diuretics, BB, vasodilators (hydrazaline), alpha blockers
initial selection: potentially favorable effects in other disease states
diuretics
- roles in managing fluid: correct underlying disease state, restrict Na intake, administration
- most pts require >2 agents: a thiazide duiretic may be 1 unless CI, combo regimens often include a diuretic, resistant HTN: failure to achieve BP goal on full doses of 3 drug regimen including a diuretic
diuretics clinical indication
HTN, edema, CHF, CKD, hypercalcemia, diabetes insipidus
may slow osteoporosis
thiazide diuretics historically..
first line for most HTN pts
more effective than loops unless CrCl
thiazide AEs
hypokalemia, hypomagnesemia, hypercalcemia, hyperuricemia, hyperglycemia, hyperlipidemia, sexual dysfunction
lithium toxicity w concurrent admin
CI: sulfa allergy
thiazide examples
HCTZ, chlorthalidone, chlorothiazide, indipamide, metolazone
loop diuretics
dose in AM or afternoon to avoid nocturnal diuresis, higher doses may be needed in pts w severely dcreased GFR or HF (use in place of thiazides when CrCl
loop diuretics AEs
hypokalemia, hypomagnesemia, hypocalcemia, hyperuricemia, ototoxicity
CI: sulfa allergy (except ethacrynic acid)
K sparing diuretic examples
amiloride, triamterene
K sparing diuretics
weak diuretics, generally used in combo w thiazide to minimize hypokalemia
K sparing diuretics AE
hyperkalemia (especially w ACE/ARB or K supplements), avoid in pts w CKD or DM
aldosterone antagonists examples
spironolactone, eplerenone
aldosterone antagonists CI
due to inc hyperkalemia, eplerenone is CrCl
aldosterone antagonists AE
hyperkalemia (especially w ACE/ARB or K supplements
avoid in CKD or DM
gynecomastia: up to 10% of patients taking spironolactone
ACE clinical indications
HTN, left ventricular systolic dysfuction, MI, diabetic nephropathy, renal artery stenosis (degree of stenosis)
ARBs clinical indications
HTN (only approved use), CHF, progressive renal impairment (diabetes)
renin inhibitors clinical indications
HTN
angiotensin compelling indications
DM w proteinuria, HF, post MI w systolic dysfunction
favorable effects of angiotensin inhibitors
DM type 1 and 2, renal insufficiency (use)
angiotensin inhibtors CI
pregnancy, nursing, hx of angioedema, bilateral renal artery stenosis, hyperkalemia
ACEI overview
“prils”
- 1st line option; strongly emphasized for CKD
- block Ang I -> Ang II
- prevent or regress left ventricular hypertrophy (LVH) by reducing ang II myocardial stimulation
ACEi monitoring
serum K+ and SCr within 4 weeks of initiation or dose increase
ACE AE
dry cough, angioedema, hyperkalemia (esp in pts with CKD or DM)
ARB overview
“sartans”
-inhibit Ang II from all pathways (directly block AT1 receptor)
ARB AE
othostatic hypotension, renal insufficiency, hyperkalemia
ACE/ARB warning
- reduce starting dose by 50% in some patients due to hypotension risk
- may cause hyperkalemia in CKD patients and patients on K sparing medications
- can cause acute kidney failure in certain patients (severe bilateral renal artery stenosis)
- CI in pregnancy
direct renin inhibitor
aliskiren
-inhibits angiotensinogen -> Ang I
renin inhibitor dosing
start: 150 mg po qd
main: 150 - 300 mg PO QD
max: 300 mg PO QD
renin inhibitor adverse events
orthostatic hypotension, hyperkalemia, diarrhea
monitoring for angiotensin inhibitors
SCr, K+, angioedema, dizziness, cough
