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Renal II Exam 3 > Anti-Hypertensives CIS > Flashcards

Anti-Hypertensives CIS Flashcards

1
Q

A 53 y/o female presents with BP of 155/90. She has a history of diabetes with hypertension currently treated with insulin and hydrochlorothiazide. Laboratory results indicate reduced GFR and proteinuria. Which drug is indicated for additional blood pressure control at this time?

A. Enalapril
B. Metoprolol
C. Nifedipine
D. Prazosin
E. Torsemide
A

A- renal protective effects– selectivity of efferent vs afferent (RIGHT ANSWER)

b- cardio selective beta blocker
c- dihydropyridine CA channel blocker
d- alpha one selective blocker
e- loop diuretic

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2
Q

A 53 y/o female presents with BP of 155/90. She has a history of diabetes with hypertension currently treated with insulin and hydrochlorothiazide. Laboratory results indicate reduced GFR and proteinuria. Which finding, if present, would contraindicate the use of angiotensin-converting enzyme inhibitors?

A. Bilateral renal artery stenosis
B. Congestive heart failure
C. Gastroesophageal reflux disease
D. Hypokalemia
E. Peripheral edema
A

A- bilateral renal artery stenosis

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3
Q

Renal Considerations with ACE Inhibitors

A

ACE inhibitors prevent/delay the progression of renal disease in type 1 diabetics and in patients with nondiabetic nephropathies (results mixed in type 2 diabetics)
ACE inhibitors vasodilate efferent arterioles > afferent arterioles
- Reduces back pressure on the glomerulus and reduces protein excretion
ACE inhibitors usually improve renal blood flow and Na+ excretion rates in CHF

In rare cases, ACE inhibitors can cause a rapid decrease in GFR, leading to acute renal failure (ARF)
- Can occur anytime during therapy, even after months/years of uneventful treatment

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4
Q

Risk Factors for ACE Inhibitor-Induced ARF

A

MAP insufficient for adequate renal perfusion

  • Poor cardiac output
  • Low systemic vascular resistance

Volume depletion (diuretic use)

Renal vascular disease

  • Bilateral renal artery stenosis
  • Stenosis of dominant or single kidney
  • Afferent arteriolar narrowing (HTN, cyclosporin A)
  • Diffuse atherosclerosis in smaller renal vessels

Vasoconstrictor agents

  • NSAIDs
  • Cyclosporine

All cause renal hypoperfusion

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5
Q

Benefits of antihypertensive therapy

A

Reduced risk of heart failure, stroke, MI (in that order)

The degree of blood pressure reduction, not the choice of antihypertensive medication, determines risk reduction.

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6
Q

Changes in Urinary Electrolytes and Body pH in response to different classes of diuretics

A

Carbonic Anydrase inhibitors –> highest level of NaHCO3 in urine

Potassium sparing –> decreased potassium in urine

Loop diuretics–> greatest amount of NaCl excreted

Thiazide diuretics–> NaCl, NaHCo3 and K+ to urine

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7
Q

Carbonic Anhydrase Inhibitors

A 
Prototype: acetazolamide
MOA: inhibits the membrane-bound and cytoplasmic forms of carbonic anhydrase
Results in:
↓ H+ formation inside PCT cell
↓ Na+/H+ antiport
↑ Na+ and HCO3- in lumen
↑ diuresis
Urine pH is increased and body pH is decreased
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8
Q

Loop Diuretics

A

Prototypes: furosemide and ethacrynic acid

MOA: inhibit the luminal Na+/K+/2Cl- cotransporter (NKCC2) in the TAL of the loop of Henle

Results in:
↓ intracellular Na+, K+, Cl- in TAL
↓ back diffusion of K+ and positive potential
↓ reabsorption of Ca2+ and Mg2+
↑ diuresis

Ion transport is virtually nonexistent

Among the most efficacious diuretics

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9
Q

Thiazide Diuretics

A

Prototype: hydrochlorothiazide (HCTZ)
MOA: cause inhibition of the Na+/Cl- cotransporter (NCC) and block NaCl reabsorption in the DCT
Results in:
↑ luminal Na+ and Cl- in DCT
↑ diuresis
Enhance the reabsorption of Ca2+ in both DCT and PCT
Largest class of diuretic agents

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10
Q

Potassium-Sparing Diuretics: 2 classes

A

Mineralocorticoid receptor Antagonists

ENaC Inhibitors

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11
Q

Mineralocorticoid Receptor (MR) Antagonists

A

Spironolactone and eplerenone
Therapeutic Use: hyperaldosteronism, adjunct to K+-wasting diuretics, antiandrogenic uses (female hirsutism), heart failure (reduces mortality)
Do not require access to the tubular lumen to induce diuresis
ADRs: hyperkalemia, acidosis, antiandrogenic

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12
Q

Na+ Channel (ENaC) Inhibitors

A

Amiloride and triamterene
Therapeutic Use: adjunct to K+-wasting diuretics and lithium-induced nephrogenic diabetes insipidus (amiloride)
ADRs: hyperkalemia and acidosis

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13
Q

A 42 y/o male presents to the ED complaining of sharp flank pain radiating to the groin, gross hematuria, and dysuria. A urine sample is obtained. Microscopy identifies a large amount of calcium oxalate crystals in the urinary sediment. He has a history of untreated hypertension and previous episodes of nephrolithiasis. Which agent would be most appropriate in this setting?

A. Acetazolamide
B. Benazepril
C. Chlorthalidone
D. Spironolactone
E. Valsartan
A

We are looking for thiazide diuretic because it increases Ca+ absorption, so the answer is

C.

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14
Q

Thiazide Diuretics

A

Prototype: hydrochlorothiazide (HCTZ)

Therapeutic Use:
- Hypertension, mild heart failure, nephrolithiasis (calcium stones), nephrogenic diabetes insipidus

ADRs: hypokalemia, alkalosis, hypercalcemia, hyperuricemia, hyperglycemia, hyperlipidemia, sulfonamide hypersensitivity

  • More hyponatremic effects than loop diuretics
  • Use with caution in patients with diabetes mellitus
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15
Q

Besides Thiazide diuretics,

What other class of diuretics can be used to treat calcium stones?

A

Potentially loop because of increased volume of urine, but not a firstline option becuase it increases Ca+ in the urine

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16
Q

A 51 y/o male presents with difficulty breathing. The patient is afebrile and normotensive, but tachypneic. Auscultation of the chest reveals diffuse wheezes. The physician provisionally makes the diagnosis of bronchial asthma and administers epinephrine by intramuscular injection, improving the patient’s breathing over several minutes. A normal chest X-ray is subsequently obtained, and the medical history is remarkable only for mild hypertension that was recently treated with propranolol. The physician instructs the patient to discontinue use of propranolol, and change the patient’s antihypertensive medication to verapamil.

Why is the physician correct to discontinue propranolol?

Why is verapamil a better choice for managing hypertension in this patient?

A

Propanalol is contraindicated in wheezing due to its bronchocontrictive effects from Beta receptor blocking effects.

Verapamil acts specifically at cardiac receptors

17
Q

β-Blocker Use in Hypertension

A

No longer 1st line treatment for hypertension, except when concomitant with a compelling indication:

  • Heart failure
  • Recent MI
  • Reduced left ventricular function

Caution in diabetes, particularly when combined with thiazide

Relative CI: asthma

Less stroke protection than other antihypertensives

18
Q

A patient has essential hypertension, and lab tests show that their circulating catecholamine and plasma renin levels are unusually high. The chosen therapeutic approach for this patient is to give a single drug that blocks both α- and β-adrenergic receptors, thereby reducing BP by reducing both CO and TPR. Which drug is most likely prescribed?

A. Carvedilol
B. Metoprolol
C. Nadolol
D. Pindolol
E. Timolol
A

A. Carvedilol

B-E beta selective blockers

19
Q

β-Blockers with α-Blocking Activity

A 
Labetalol
Selective alpha 1 blocker
Nonselective beta 1 & beta 2 blocker
Partial agonist at b2 
Therapeutic Use: 
- IV for severe hypertension
- Acceptable option for hypertension during pregnancy

Carvedilol
Nonselective b-blocker + a1-blocker
Also has antioxidant properties

20
Q

A patient presents to the ED with acute hypotension that requires treatment. Hypovolemia is ruled-out as a cause or contributor, and information gathered from the patient and family indicates that the cause is overdose of an antihypertensive drug. One approach to treatment is to administer a pharmacologic (ordinarily effective) dose of phenylephrine. You do just that, and BP fails to rise at all—and a second dose doesn’t work either. On which drug did the patient most likely overdose?

A. Atenolol
B. Nicardipine
C. Prazosin
D. Propranolol
E. Verapamil
A

C. Prazosin, alpha 1 selective

phenylephrine is an alpha 1 agonist

atenolol- beta blocker
nicardipine- dihydropyridine CCB
Propanalol- beta blocker
Verapamil- non-dihydropyridine CCB

21
Q

alpha 1-Selective Receptor Blockers

A

MOA: prevent vasoconstriction of both arteries and veins
↓ total peripheral resistance, ↓ venous return, ↓ preload
Usually do not ↑ heart rate or cardiac output
Do not ↑ NE release (no 2 block)
Favorable effects on lipids (↓ LDL & triglycerides; ↑ HDL)
Relaxes smooth muscle in the prostate
Therapeutic Use: 3rd or 4th line treatment of essential hypertension; added to other agents from different classes in refractory cases; also used in men with concurrent HTN and BPH
ADRs: postural hypotension & syncope, especially with initial doses; usually given at bedtime to minimize hypotensive effects

22
Q

selectiity of alpha blockers

A

alpha 2 receptors are on the cell releasing the NE, alpha 1 receptors on the receiving cell

Phentolamine blocks both (leads to release of more NE), prazosin just the alpha 1 receptors

23
Q

A 28 y/o woman is receiving drug therapy for essential hypertension. She subsequently becomes pregnant. You realize that the drug she’s been taking for her high blood pressure can have serious, if not fatal, effects on the fetus. As a result, you stop the current antihypertensive drug and substitute another that is deemed to be equally effective in terms of her blood pressure, and safer for the fetus. Which drug was she most likely taking before she became pregnant?

A. α-Methyldopa
B. Captopril
C. Furosemide
D. Labetalol
E. Verapamil
A

B. Captopril is an ACE inhibitor, teratogenic

Now we’ve probably switched her to methyldopa. labetalol could also be ok.

24
Q

Methyldopa

A

False neurotransmitter concept:
- Converted to methyl-NE
- Stored in vesicles instead of NE
- Released & acts as a centrally acting α2-agonist
- Decreases central sympathetic outflow & decreases blood pressure
Therapeutic Use: only used to treat hypertension in pregnancy because of its safety
ADRs (many): sedation, dry mouth, sexual dysfunction, postural hypotension, anemia

25
Q

Clonidine

A

An a2-adrenergic receptor agonist

  • IV - increase BP (peripheral a2B) followed by decreased BP (central a2A)
  • Oral - decreased BP (decreased C.O., preload)
  • Patch - same as oral

Therapeutic Use:

  • Essential hypertension (rarely used)
  • Adjunct for narcotic, alcohol, & tobacco withdrawal (unlabeled)

ADRs:

  • Dry mouth, sedation, impotence, depression
  • Sudden withdrawal causes hypertensive crisis
26
Q

Hypertension in Pregnancy

A

Maternal benefit is well-established for treatment of severe hypertension (systolic pressure ≥ 160 mmHg and/or diastolic pressure ≥ 110) in reduction of stroke risk
Long-Term Oral Therapy Options
- Methyldopa
- Beta-blockers: labetalol, pindolol, metoprolol
- Calcium channel blockers: nifedipine, nicardipine
- Hydralazine: monotherapy carries risk of reflex tachycardia, can be used as add-on therapy with methyldopa or labetalol

Drugs to Avoid

  • ACE inhibitors, ARBs, direct renin inhibitors
  • Nitroprusside
27
Q

A 45 y/o male is brought to the ED with signs of delirium. His blood pressure is 220/160 and he has retinal hemorrhages. A short-acting agent that binds to voltage-gated ion channels is administered by intravenous infusion in an effort to lower his blood pressure. Which drug best fits this description?

A. Clevidipine
B. Enalaprilat
C. Fenoldopam
D. Hydralazine
E. Nitroprusside
A

A. Clevidipine binds voltage gated ion channels– CCB

Hydralazine and nitroprusside are both vasodilators via nitric oxide (cGMP)

Fenoldopam- g protein coupled receptor

Enalaprilat- ACE inhibitor (enzyme inhibitor)

28
Q

Drugs for Hypertensive Emergencies

A

Goal: controlled and gradual lowering of blood pressure without excessive hypotension that could lead to myocardial infarction, stroke, or loss of vision

Vasodilators:
Sodium nitroprusside
Nitroglycerin
Nicardipine
Clevidipine
Fenoldopam
Hydralazine
Enalaprilat
Adrenergic Antagonists:
Labetalol
Metoprolol
Esmolol
Phentolamine
29
Q

Summary: Clinical Pharmacology- initial monotherapy

A

Initial Monotherapy:
Thiazide diuretic
ACE inhibitor or ARB
– Renoprotective (always use first in CKD +/- diabetes)
– Less effective antihypertensive in individuals of African descent
– Do not combine direct RAS inhibitors (ACE inhibitors, ARBs, or renin inhibitors)
Calcium channel blocker
– β-blockers are not typically used in the absence of a specific indication

30
Q

Summary: Clinical Pharmacology: polypharmacy

A

Two or three drugs at half-standard doses might have greater efficacy and less toxicity than one drug at standard or twice-standard dose

31
Q

Management Algorithm in JNC8:

A

http://jama.jamanetwork.com/article.aspx?articleid=1791497

32
Q

add the compelling indications here

A

x

33
Q

increased Na and K+ presentation to the collecting ducts leads to

A

increased pH in the body

Renal II Exam 3 (15 decks)

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