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Fall 2020: Therapeutics 2 > Anti-Hypertensives > Flashcards

Anti-Hypertensives Flashcards

1
Q

List the thiazide diuretics.

A
  • Chlorthalidone
  • HCTZ
  • Indapamide
  • Metolazone
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2
Q

How are thiazides administered?

A

QD in the morning

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3
Q

What adverse effects are associated with thiazides?

A
  • Hypokalemia
  • Hypomagnesemia
  • Hypercalcemia
  • Hyperuricemia
  • Hyperglycemia
  • Hyperlipidemia
  • Sexual dysfunction
  • Increased TGs/cholesterol
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4
Q

What do thiazides interact with?

A

Lithium toxicity with concurrent use

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5
Q

When are thiazides contraindicated?

A

Sulfa allergy and anuria

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6
Q

What should be monitored if a patient is on a thiazide?

A
  • BUN/SCr
  • Electrolytes
  • Uric acid
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7
Q

What trial determined that thiazides should be first-line for most HTN patients?

A

ALLHAT

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8
Q

When are thiazides more effective than loops?

A

When CrCl >30

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9
Q

Which thiazide is 1-2x more potent than HCTZ?

A

Chlorthalidone

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10
Q

List the loop diuretics.

A
  • Furosemide
  • Torsemide
  • Bumetanide
  • Ethacrynic acid
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11
Q

How are loop diuretics administered?

A

QD-BID in the morning (torsemide is QD only)

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12
Q

What adverse effects are associated with loop diuretics?

A
  • Hypokalemia
  • Hypomagnesemia
  • Hypocalcemia
  • Hyperuricemia
  • Ototoxicity
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13
Q

When are loop diuretics contraindicated?

A

Sulfa allergy

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14
Q

What should be monitored in a patient taking a loop diuretic?

A
  • BUN/SCr
  • Electrolytes
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15
Q

Although loop diuretics aren’t first-line treatment, when are they preferred?

A

For heart failure symptom management

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16
Q

When are loops more effective than thiazides?

A

When CrCl <30

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17
Q

Which drug class has a high-ceiling dose response curve?

A

Loop diuretics

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18
Q

List the aldosterone antagonists.

A

Spironolactone and eplerenone

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19
Q

How should aldosterone antagonists be administered?

A

QD-BID in the morning/afternoon

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20
Q

List the adverse effects associated with aldosterone antagonists.

A
  • Hyperkalemia
  • Hyponatremia
  • Gynecomastia (spironolactone)
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21
Q

What do aldosterone antagonists interact with?

A

ACEi/ARBs/renin inhibitors/NSAIDs increase hyperkalemia risk

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22
Q

When are aldosterone antagonists contraindicated?

A

Eplerenone:

  • Renal impairment
  • T2DM with proteinuria

Both:

  • Concomitant use of potassium-sparing diuretics
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23
Q

What should be monitored in a patient taking an aldosterone antagonist?

A
  • BUN/SCr
  • Potassium
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24
Q

Which aldosterone antagonist is preferred with resistant hypertension?

A

Spironolactone

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25
Q

What trial demonstrated that spironolactone is preferred for resistant hypertension?

A

PATHWAY-2

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26
Q

At what K level should aldosterone antagonists NOT be initiated?

A

When K >5 mEq/L

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27
Q

At what K level should you consider holding/reducing an aldosterone antagonist? At what SCr increase?

A
  • When K >5.5 mEq/L
  • When SCr increases >25%
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28
Q

List the potassium-sparing diuretics.

A

Amiloride and triamterene

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29
Q

How should potassium-sparing diuretics be administered?

A

QD-BID in the morning

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30
Q

List the adverse effects associated with potassium-sparing diuretics.

A
  • Hyperkalemia
  • Increased uric acid
  • Hyperglycemia
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31
Q

What parameters should be monitored in a patient taking a potassium-sparing diuretic?

A
  • BUN/SCr
  • Electrolytes
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32
Q

Since potassium-sparing diuretics are not used as a monotherapy for hypertension, what drug clas should they be combined with?

A

Thiazides (to minimize hypokalemia)

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33
Q

Caution should be used when administering potassium-sparing diuretics in what two disease states?

A
  • Diabetes
  • CKD (GFR <45)
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34
Q

List the ACE inhibitors.

A
  • Benazepril
  • Captopril
  • Enalapril
  • Fosinopril
  • Lisinopril
  • Moexipril
  • Perindopril
  • Quinapril
  • Ramipril
  • Trandolapril
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35
Q

How should ACE inhibitors be administered?

A

QD-TID (good option for PM dosing)

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36
Q

List the adverse effects associated with ACE inhibitors.

A
  • Angioedema
  • Cough
  • Hyperkalemia
  • Acute renal failure with severe bilateral renal artery stenosis
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37
Q

When are ACE inhibitors contraindicated?

A
  • History of angioedema on an ACEi
  • Use of aliskiren in diabetics
  • Pregnancy/breastfeeding
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38
Q

What should be monitored in patients on an ACE inhibitor?

A
  • BUN/SCr
  • Potassium
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39
Q

ACE inhibitors are shown to have additional benefits in which patient populations?

A
  • Diabetes with proteinuria
  • Heart failure
  • Post-MI
  • CKD
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40
Q

Explain the anti-hypertensive effects of ACE inhibitors.

A
  • Vasodilation
  • Reduced PVR
  • Increased diuresis
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41
Q

At what K level should you consider holding/reducing ACE inhibitor doses? At what SCr increase?

A
  • When K >5.5 mEq/L
  • When SCr increases >30%
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42
Q

List the ARBs.

A
  • Azilsartan
  • Candesartan
  • Eprosartan
  • Irbesartan
  • Losartan
  • Olmesartan
  • Telmisartan
  • Valsartan
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43
Q

How should ARBs be administered?

A

QD-BID (good option for PM dosing)

44
Q

What adverse effects are associated with ARBs?

A
  • Angioedema
  • Hyperkalemia
  • Acute renal failure with severe bilateral renal artery stenosis
45
Q

When are ARBs contraindicated?

A
  • History of angioedema on an ARB
  • Use of aliskiren in diabetics
  • Pregnancy/breastfeeding
46
Q

What should you monitor in patients taking ARBs?

A
  • BUN/SCr
  • Potassium
47
Q

Why do ARBs tend to cause less cough?

A

They don’t block bradykinin breakdown

48
Q

Explain the anti-hypertensive effects of ARBs.

A
  • Vasodilation
  • Reduced PVR
  • Increased diuresis
49
Q

When should you consider holding/reducing the dose of an ARB?

A
  • When K >5.5 mEq/L
  • When SCr increases >30%
50
Q

List an example of a direct renin inhibitor.

51
Q

What adverse effects are associated with aliskiren?

A
  • Diarrhea
  • Musculoskeletal effects (CK increase)
  • Dizziness
  • Headache
  • Hyperkalemia
  • Renal insufficiency/ARF
  • Orthostatic hypotension
52
Q

When is aliskiren contraindicated?

A
  • Concomitant use of ACEi/ARBs in diabetics
  • Pregnancy/breastfeeding
53
Q

What should be monitored in patients taking aliskiren?

A
  • BUN/SCr
  • Potassium
54
Q

Why does aliskiren not cause much of a cough?

A

It doesn’t block bradykinin breakdown

55
Q

How should aliskiren be administered?

56
Q

List some examples of dihydropyridine CCBs.

A
  • Amlodipine
  • Felodipine
  • Israldipine
  • Israldipine SR
  • Nicardipine SR
  • Nifedipine LA
  • Nisoldipine
57
Q

How should dihydropyridine CCBs be administered?

A

QD-BID (isradipine and nicardipine SR are BID)

58
Q

What adverse effects are associated with dihydropyridine CCBs?

A
  • Reflex tachycardia
  • Flushing
  • Dizziness
  • Headache
  • Peripheral edema (dose-related)
  • Gingival hyperplasia
59
Q

What warnings are associated with dihydropyridine CCBs?

A

Increased risk of angina/MI in patients with obstructive coronary disease due to reflex tachycardia

60
Q

What interactions exist with dihydropyridine CCBs?

A
  • Grapefruit juice
  • CYP3A4 inducers/inhibitors
61
Q

Dihydropyridine CCBs have additional benefit in which patient populations?

A
  • Reynaud’s
  • Elderly patients with isolated systolic HTN
62
Q

Complete the sentence: dihydropyridine CCBs are more potent ___________ than non-dihydropyridine CCBs.

A

vasodilators

63
Q

Why should short-acting dihydropyridines (IR nifedipine/nicardipine)?

A

Reflex tachycardia

64
Q

Which two dihydropyridine calcium channel blockers have no negative inotropic effects?

A

Amlodipine and felodipine

65
Q

List the non-dihydropyridine CCBs.

A
  • Diltiazem ER
  • Verapamil ER
66
Q

What adverse effects are associated with non-dihydropyridine CCBs?

A
  • Bradycardia
  • Headache
  • Dizziness
  • AV node block
  • Systolic HF
  • Gingival hyperplasia
  • Constipation (verapamil > diltiazem)
67
Q

What interactions exist with non-dihydropyridine CCBs?

A
  • Concomitant use of beta blockers (increases heart block risk)
  • Grapefruit juice
  • CYP3A4 inducers/inhibitors
68
Q

When are non-dihydropyridine CCBs contraindicated?

A
  • Heart block
  • Left ventricular dysfunction
69
Q

What should be monitored in patients taking non-dihydropyridine CCBs?

A

Heart rate

70
Q

Non-dihydropyridine CCBs are shown to have additional benefit in which patient populations?

A
  • Supraventricular tachyarrhythmias (atrial fibrillation)
  • Patients with angina who don’t tolerate beta blockers
71
Q

Explain the negative inotropic effect of non-dihydropyridine CCBs.

A

Slow AV node conduction and decrease heart rate

72
Q

Which formulation of non-dihydropyridine CCBs are preferred for hypertension?

A

Extended-release

73
Q

List the cardioselective beta blockers.

A
  • Atenolol
  • Betaxolol
  • Bisoprolol
  • Metoprolol tartrate/succinate
  • Nebivolol
74
Q

How are cardioselective beta blockers administered?

A

QD-BID (metoprolol tartrate)

75
Q

What adverse effects are associated with beta blockers?

A
  • Bronchospasm
  • Bradycardia
  • Fatigue
  • Exercise intolerance
  • Depression
76
Q

When are beta blockers contraindicated?

A
  • 2nd/3rd degree heart block
  • Decompensated heart failure
  • Post-MI (ISA only)
  • Severe bradycardia
  • Sick sinus syndrome
77
Q

Since beta blockers are not first-line for HTN unless a compelling indication is present, what compelling indications are there?

A

Heart failure and CAD

78
Q

Beta blockers are shown to have additional benefit in which patient populations?

A
  • Tachyarrhythmias
  • Tremors
  • Migraines
  • Thyrotoxicosis
79
Q

How do beta blockers decrease CO?

A

Decrease heart rate and force of contraction

80
Q

Can you discontinue beta blockers immediately?

81
Q

Which beta blocker has nitric oxide-indued vasodilation?

82
Q

List the nonselective beta blockers.

A
  • Nadolol
  • Propranolol IR/LA
83
Q

How should nonselective beta blockers be administered?

A

QD-BID (propranolol IR)

84
Q

When should nonselective beta blockers be avoided?

A

Bronchospastic airway disease

85
Q

List the ISA beta blockers.

A
  • Acebutolol
  • Penbutolol
  • Pindolol
86
Q

How should ISA beta blockers be administered?

A

QD (penbutolol) - BID

87
Q

When should ISA beta blockers be avoided?

A

Heart failure and IHD

88
Q

List the mixed alpha/beta blockers.

A

Carvedilol and labetalol

89
Q

How should mixed alpha/beta blockers be administered?

90
Q

What beta blocker is preferred in patients with peripheral artery disease?

A

Carvedilol

91
Q

What class of beta blocker is preferred with reactive airway disease?

A

Cardioselective beta blockers

92
Q

What should you monitor in patients taking beta blockers?

A

Heart rate

93
Q

List the direct arterial vasodilators.

A

Hydralazine and minoxidil

94
Q

How is minoxidil administered?

95
Q

How is hydralazine administered?

96
Q

What adverse effects are associated with direct arterial vasodilators?

A
  • Palpitations
  • Tachycardia
  • Chest pain
  • GI side effects
  • Headache
  • Hematologic dyscrasias
  • Hepatotoxicity
  • Lupus-like syndrome/rash (hydralazine)
  • Fluid retention
  • Hair growth (minoxidil)
97
Q

What warnings are associated with direct arterial vasodilators?

A
  • May cause pericarditis/pericardial effusion that may progress to tamponade
  • May increase O2 demand and exacerbate angina pectoris
  • Max therapeutic doses of a diuretic and 2 other anti-hypertensives should be used before these are ever added; should be given with a diuretic to minimize gluid gain and a beta blocker
98
Q

Direct arterial vasodilators are only indicated for patients with special indications or very difficult-to-control BP. List some of these conditions.

A

Severe CKD, hemodialysis

99
Q

Which is more potent: minoxidil or hydralazine?

100
Q

Direct arterial vasodilators should be used in caution with what conditions?

A
  • CVA
  • Renal impairment
  • CAD
  • Liver disease
  • SLE
101
Q

List the alpha-1 blockers.

A
  • Doxazosin
  • Prazosin
  • Terazosin
102
Q

What adverse effects are associated with alpha-1 blockers?

A

Orthostatic hypotension (especially in the elderly)

103
Q

Alpha-1 blockers are second-line for HTN in which patients?

A

HTN patients with concomitant BPH

104
Q

List the central alpha-2 agonists.

A
  • Clonidine
  • Methyldopa
  • Guanfacine
105
Q

How should clonidine be administered?

Fall 2020: Therapeutics 2 (11 decks)

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