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Semester 1 Finals > Antihypertensives > Flashcards

Antihypertensives Flashcards

1
Q

First Line Drug Classes

A
  • ACES
  • ARBS
  • Thiazide Diuretics
  • Calcium Channel Blockers
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2
Q

Examples of Rx-induced causes of HTN

A
  • amphetamines
  • corticosteroids
  • NSAIDs
  • estrogen-containing oral contraceptives
  • anabolic steroids
  • tacrolimus, cyclosporine - calcineurin inhibitors (transplant)
  • venlafaxine (Effexor) or desvenlafaxine (Pristiq) (antidepressants)
  • oral decongestants – pseudoephedrine/phenylephrine
  • abruptly stopping BETA-blocker therapy
  • abruptly stopping central acting, ALPHA- antagonist therapy
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3
Q

Examples of non-Rx-induced causes of HTN

A
  • drugs of abuse
    cocaine/cocaine withdrawal, nicotine withdrawal, narcotic withdrawal, phencyclidine (PCP)
  • dietary supplements/foods
    sodium intake, alcohol (ethanol) intake, dietary supplements (ex. St. Johns Wort; herbal ecstacy, bitter orange, guarana, kava, high dose licorice), tyramine-containing foods (wine, aged cheese, etc) with “MOA inhibitors” (antidepressant)
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4
Q

ACE inhibitors

A

Function: prevents conversion from angiotensin I to angiotensin II

  • captoPRIL
  • benazaPRIL
  • enalaPRIL
  • fosinoPRIL
  • lisinoPRIL
  • quinaPRIL
  • ramiPRIL
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5
Q

Direct renin inhibitor

Medication
Side effects

A

aliskiren

Side effects: hyperkalemia, hypotension

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6
Q

Side effects of ACE inhibitors

A
  • hypotension
  • hyperkalemia
  • cough
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7
Q

Side effects of ARBs

A
  • hypotension
  • hyperkalemia

NO cough (different from an ACE)

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8
Q

Among the first line Rxs, avoid the combination of THESE THREE DRUGS due to _____________

A

DRI, ACEs, ARBs

due to dual RAAS blockage

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9
Q

Adverse Effects of ACE/ARB/DRI + patient populations to watch out for

A
  1. dizziness/hypotension
    - be careful with HYPOVOLEMIC and ELDERLY patients
  2. hyperkalemia
    - be careful with ELDERLY, DM, CKD patients
  3. non-productive dry cough (ACE ONLY)
    - common; resolves upon d/c; drug class intolerance > don’t rechallenge
  4. increased SCr
    - expect to see increase SCr with decrease GFR 5-14 days initiation/dose increase
    - should rise <30%, anything over indicates unstable progressive renal damage/AKI
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10
Q

RARE Adverse Effects of ACE/ARB/DRI

A

hepatoxicity, neutropenia, angioedema

  • serious hypersensitivity (allergic) rxn > consider allergy across ALL of ACEs/ARBs/DRIs
  • occurs more frequently in black pts
  • more common with ACEs
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11
Q

Contraindications of ACE/ARB/DRI

A
  • known hypersensitivity
  • pregnancy!!!!!
  • bilateral renal artery stenosis
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12
Q

Precautions of ACE/ARB/DRI

A
  • volume depletion/dehydration (correct before initial dosage)
  • pre-existing hyperkalemia
  • women of child-bearing age
  • risk for acute renal injury
  • existing CKD
  • renal artery stenosis, systolic HF, volume depletion (concurrent diuretics), concurrent nephrotoxicity risks (NSAIDs including HIGH dose aspirin)
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13
Q

Monitoring ACE/ARB/DRI

A

1-2 weeks initial impact (esp. high risk)
4 weeks for full BP lowering impact

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14
Q

Thiazide diuretics

A
  1. hydrochloroTHIAZIDE (HCTZ)
  2. chloroTHIAZIDE
  3. chlorthalidone
  4. indapamide
  5. metolazone
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15
Q

Calcium channel blockers

A

DHP
- amloDIPINE
- feloDIPINE
- israDIPINE
- nifeDIPINE
- nicarDIPINE

non-DHP
- verapamil
- diltiazem

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16
Q

Thiazide diuretics that DON’T have the same endings

A

chlorthalidone
indapamide
metolazone

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17
Q

non-DHP drugs

A

verapimil
diltiazem

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18
Q

metolazone

A
  • very potent “thiazide-like” diuretic
  • not common for HTN in general pop.
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19
Q

For thiazide diuretics, you should generally avoid CrCl of ______ mL/min

A

<30 mL/min

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20
Q

DHP vs. Non-DHP

A

DHP
- nifedipine, amlodipine
- more potent peripheral vasodilators
- common side effects = peripheral edema, headache
- uncommon = dizziness/orthostasis, flushing, nausea, GERD, gingival hyperplasia, REFLEX tachycardia (esp with nifedipine)

Non-DHP
- verapamil, diltiazem
- less potent peripheral vasodilators
- common side effects = bradycardia, potential cardiac conduction abnormalities, systolic HF (AVOID USE EF <40%) due to negative inotropic effects, constipation
- uncommon: nausea, GERD, headache, dizziness, flushing (less vs. DHP)

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21
Q

CCB Adverse Effects

A
  • pregnancy/lactation (avoid lactation)
  • hepatic/renal dysfunction

NON-DHP only
- beta blocker, cardiac conduction abnormalities, systolic HF/LV dysfunction

DHP only
- AVOID short-acting release nifedipine – risk of severe reflex tachycardia/rebound HTN with risk of MI/CVA
- nifedipine XL - avoid in systolic HF/LV dysfunction – AMLODIPINE OK
- migraines (worsen)

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22
Q

Avoid Non-DHP with __________

A

beta-blocker

WHY?
- additive risk for bradycardia + AV block
- reserve use for specialists

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23
Q

Major P450-drug interactions

A

Verapamil, diltiazem, + nifedipine = 3A4 inhibitors
- increase erythromycin
- increase digoxin levels by 50%
- major interactions with simvastatin
20 mg/day with amlodipine
10 mg/day with verapamil or diltiazem
- drug-food/drug-herb interactions
> 1L/day grapefruit juice

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24
Q

How would you check the efficacy of your ACEi/ARB/DRI ?

A

By monitoring the systolic and diastolic BP

25
Q

How would you check the safety of your ACEi/ARB/DRI ?

A

By monitoring the SCr, K+ (via BMP or CMP)

26
Q

Elevated SCr indicates what?

A

Elevated SCr = >30-35%

indicates unstable, progressive renal damage OR acute kidney injury (AKI)

27
Q

Diuretics used for HTN

A
  1. thiazide (first line)
  2. loop
  3. K+ -sparing
  4. aldosterone-antagonist (ALDO antagonists)
28
Q

Which subclass + med causes the risk of severe reflex tachycardia/rebound HTN with risk of MI/CVA?

A

Subclass = DHP (CCB)
Med = nifedipine (amlodipine OK)

29
Q

What first line class of meds are preferred for African Americans?

A

THZ + CCB

30
Q

What first line class of meds are preferred for people with comorbidities including CAD, CKD, DM, prior stroke, systolic HF?

A

ACEi + ARB

31
Q

Which diuretics are reserved use for HTN?

A

Loop + K+ sparing diuretics

32
Q

What class of non-first line meds are preferred for people with comorbidities including CAD and systolic HF?

A

BB

33
Q

What class of non-first line meds are preferred for people with comorbidities including systolic HF and post-MI with LVD?

A

ALDO antag

34
Q

Can you use a CCB in someone with systolic HF?

A

YES as long as
1. it’s not nifedipine
2. EF >40%

35
Q

Which CCB would be okay to use in someone with systolic HF/LV dysfunction?

A

Amlodipine

36
Q

When would you want to use a loop diuretic over a THZ?

A

2 populations where you need to retain fluid/sodium

  1. Ppl with CKD with CrCl < 30 mL/min - THZ not as good at < 30 mL/min
  2. Ppl with systolic HF + edema - provides more diuresis than a THZ
37
Q

Loop diuretic endings

A

-mide

  • furosiMIDE
  • torseMIDE
  • bumetanIDE
  • ethacrynic acid
38
Q

If you have an allergy to sulfas, what drug class should you avoid?

A

loop diuretics
with the exception of ethacrynic acid

39
Q

Which diuretic is NOT GOOD for long term use?

A

loop diuretics - caps over time

thiazides are better in conjunction with ACEi/ARB

40
Q

Another name for K+ sparing diuretics

A

Aldosterone antagonist

41
Q

Examples of K+ sparing diuretics

A
  • spironolactONE
  • eplerenONE
  • triamterene
  • amiloride
42
Q

When would you use a K+ sparing diuretic?

A

RESERVED USE - an option to limit hypokalemia
- in combo with THZ
- offers relatively WEAK anti-HTN
- increased hyperkalemia risk when used with ACEi

43
Q

Gynecomastia is a side effect of which drug?

A

spironolactone

  • preferred in women
44
Q

Spironolactone vs. eplerenone

A

spironolactone preferred - cheaper
- reduce dose if CrCl 31-50 mL/min
- avoid if CrCl < 30 mL/min
- effective ADD-ON

eplerenone - less side effects
- avoid if CrCl < 50 mL/min
- more expensive

45
Q

Metabolic adverse effects of diuretics

A

ALL: hyponatremia
loop>THZ: hypokalemia, hypomagnesemia
K+: HYPERkalemia

high dose THZ or loop:
- hyperglycemia
- hyperlipidemia

46
Q

Agents with NO impact on cholesterol

A

indapamide and K+ sparing (ALDO ANTAG)

47
Q

Absolute contraindication of diuretics

A

anuria

48
Q

You should be especially careful with loop diuretics because of …

A

ototoxicity, dehydration (hypovolemia)

49
Q

What diuretic puts you at risk for gout?

A

THZ

50
Q

At high dose THZ or loop, you should be careful of…

A

hyperglycemia, uncontrolled lipid levels

51
Q

General warnings of diuretics

A
  • Preexisting electrolyte imbalance
  • CKD
  • severe hepatic disease
  • women of childbearing age / lactation
52
Q

Combining WHAT drugs raises potassium levels

A

KCL; ACEI; ARB; DRI; K+ sparing/

53
Q

Interaction between digoxin and diuretics

A

K+ wasting diuretics make digoxin more toxic; related to cardiac arrhythmias

loop»>THZ

54
Q

This metal should be avoided with THZ/loop

A

lithium

  • reduces lithium clearance
  • risk of lithium toxicity
55
Q

What causes an 85% reduction of HCTZ absorption?

A

cholestyramine

56
Q

Which drug causes a clinically significant increase in hyperkalemia risk with 1 grapefruit or 1 cup of juice?

A

eplerenone

57
Q

Serum levels of the diuretics

A

All: ↓ Na+
Loop»THZ: ↓ K+, Mg2+
Loop: ↓ Ca2+
THZ: ↑ Ca2+
THZ>loop: ↑ uric acid - GOUT
Loop/THZ: ↑ glucose, lipids (high dose)
K+ sparing: ↑ K+

↑ THZ (except K+, Mg2+)
↓ Loop (except glucose/lipids)

58
Q

Lupus is associated with what drug?

A

Methyldopa

Semester 1 Finals (4 decks)

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