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Pharm II - antihypertensive therapies > Antihypertensives and Statins > Flashcards

Antihypertensives and Statins Flashcards

1
Q

What are the two types of hypertension?

A
  1. essential (>90%)

2. secondary (10%)

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2
Q

What are some of the etiologies of secondary hypertension?

A
  1. CKD
  2. renovascular dz
  3. pregnancy
  4. Cushing’s (increased aldosterone)
  5. drug induced (cocaine)
  6. tumor (pituitary)
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3
Q

What is total peripheral resistance?

A

Sum of peripheral resistance in the peripheral vasculature (represents diastolic BP).

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4
Q

Cardiac output

A

The amount of blood pumped out by the ventricles (represent systolic BP).

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5
Q

What are the mechanisms of pathogenesis?

A
  • Increased peripheral resistance.

- Increased cardiac output.

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6
Q

What is the pathogenesis of increased peripheral resistance?

A

Functional vascular constriction/Structural vascular hypertrophy

  • over activity of sympathetic nervous system (increased epi & NE) = increased contraction and BP
  • genetic components
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7
Q

What is the pathogenesis of increased cardiac output?

A
  • Increased preload due to:
    1. increased fluid volume
    2. excess sodium intake
    3. renal sodium retention
  • venous constriction
    1. excess RAAS stimulation (renin-aldosterone system). Increased aldosterone=increased fluid and constriction.
    2. sympathetic nervous system overactivity
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8
Q

What is the JNC BP goal for patients > 60 years old?

A

It is

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9
Q

What is the JNC BP goal for patients 60 and under?

A

It is

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10
Q

What is the JNC BP goal for patients with DM and CKD?

A

It is

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11
Q

What are some non-pharmacological therapies for reduction of HTN?

A
  1. lifestyle modification
  2. smoking cessation
  3. weight loss
  4. DASH diet
  5. dietary sodium reduction
  6. increased physical activity
  7. limit alcohol intake (1 female/2 male)
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12
Q

What is the most effective non-pharm therapy?

A

weight loss

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13
Q

What is first line pharmacologic treatment option for HTN?

A

Thiazides, CCB, ACE-I, ARBs

ALL ARE EQUAL IN CHOICE

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14
Q

Which therapies are not the best choices for treating HTN in African americans?

A

ACE-I

ARBs

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15
Q

What are the best choices for HTN tx in DM or CKD patients?

A

ACE-I or ARBs

DO NOT USE TOGETHER - EITHER/OR

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16
Q

What is the best choice for HTN tx in patients with cardiac hx?

A

beta blockers

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17
Q

Which HTN classes are best to use in African americans?

A

thiazides, CCBs

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18
Q

1st option treatment approach?

A

IN ADDITION TO NONPHARM THERAPY: Start with 1 drug and max the dose then add a 2nd agent. If still not at goal, add a 3rd agent once the 2nd agent is maxed out.

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19
Q

2nd option treatment approach?

A

IN ADDITION TO NONPHARM THERAPY: Start with 1 drug and if not at goal add a 2nd drug prior to maxing out the dose on the first. Then max the dose on both drugs and if not at goal add 3rd agent. Most used in the “real world.”

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20
Q

3rd option treatment approach?

A

IN ADDITION TO NONPHARM THERAPY: Start with 2 drugs from the beginning if the SBP>160 and/or the DPB>100. Max out the drug doses and add on a 3rd agent if needed.
EXAM ONLY PURPOSES.

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21
Q

Thiazide Diuretics

A

HCTZ
chlorthalidone
metolzaone

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22
Q

Thiazide MOA

A

Inhibits sodium reabsorption in the distal tubule.

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23
Q

Metolzaone

A

Used in patients with heart failure that Lasix does not work for!

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24
Q

Which drug class is first line for tx of HTN?

A

Thiazide diuretics

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25
Q

What is the typical thiazide dose?

A

25 mg (can start at 12.5 mg)

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26
Q

What are the adverse effects of thiazide diuretics?

A
  • orthostatic hypotension
  • decreased K, Na
  • increased Ca, URIC ACID, glucose
  • photosensitivity
  • increased urination (typically will decrease)
  • increased lithium concentrations
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27
Q

What are some precautions when using thiazide diuretics?

A
  • use with caution in sulfa allergic patients (typically those with prior anaphylaxis)
  • INEFFECTIVE IN PTS WITH SEVERE RENAL DISEASE!!! Creatinine
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28
Q

What prior conditions would you avoid giving a thiazide diuretic?

A
  • GOUT

- SEVERE RENAL DZ

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29
Q

Loop Diuretic drugs

A
  • furosemide (Lasix)
  • bumetanide (Bumex)
  • torsemide (Demadex)
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30
Q

Hydochlorathiazide

A

thiazide diuretic

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31
Q

Chlorthalidone

A

thiazide diuretic

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32
Q

Metolzaone

A

thiazide diuretic

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33
Q

Loop MOA

A

Inhibits active transport of Na, Cl, and K in thick ascending limb of Loop of Henle, causing EXCRETION of the ions.
RESULT= collecting duct excretes more H2O in response.

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34
Q

Furosemide

A

Lasix (brand name)
The most potent loop diuretic.
1st choice tx in CHF.

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35
Q

Bumetanide

A

Bumex (brand name)

Loop diuretic. Not as potent as furosemide.

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36
Q

Torsemide

A

Demadex (brand name)

Least potent loop diuretic

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37
Q

Loop diuretics are typically 1st choice for what pathology?

A
  • CHF
  • Peripheral and pulmonary edema
  • HTN
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38
Q

Adverse effects of loop diuretics

A 
Decreased K, Na, Ca, Mg
Increased uric acid
Increased serum creatinine
Dehydration
Ototoxicity (if combined with another aminoglycoside abx)
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39
Q

Loop diuretics - precautions

A

Use with caution in pts with sulfa allergies

  • nephrotoxicity
  • Do not use in patients with GOUT!
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40
Q

If you were to give a second dose of Lasix, what would the frequency be?

A

After first dose, can give another dose 6 hours later. Don’t give the dose later than 4pm!

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41
Q

What are two types of potassium sparing diuretics?

A
  • Aldosterone receptor blockers

- Potassium sparing

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42
Q

What are the aldosterone receptor blockers?

A
  • spironolactone (Aldactone)

- eplerenone (Inspra)

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43
Q

MOA of Aldosterone Receptor Blockers

(ARBs)

A

Competes with aldosterone, prevents sodium reabsorption and potassium excretion.

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44
Q

MOA of Potassium Sparing Drugs?

A

Blocks sodium reabsorption and potassium excretion, effect independent of aldosterone.

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45
Q

Aldosterone Receptor blocker drugs

A
  • spironolactone

- eplerenone

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46
Q

Potassium sparing drugs

A

-triamterene
-amiloride
These are not used by themselves. Usually paired with a thiazide.

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47
Q

In what area do potassium sparing drugs work?

A

In the collecting duct. Very distal.

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48
Q

What are potassium sparing drugs used to treat?

A

HTN.

Class IV heart failure. Has mortality benefit!

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49
Q

Adverse effects of loop diuretics

A

Hyperkalemia - use with caution in RENAL PTs

  • Spironolactone may cause gynecomastia, menstrual irregularities.
  • Eplerenone is less selective = Less side effects!
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50
Q

Which loop diuretic has potential mortality benefit?

A

spironolactone

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51
Q

ACE inhibitors MOA

A
  • Inhibits ACE to block production of angiotensin II
  • Inhibits breakdown of vasodilator bradykinin
  • Dilates efferent arteriole of the kidney
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52
Q

Inhibition of bradykinin is bad because?

A

Increased levels of bradykinin cause cough in about 20% of patients taking ACE inhibitors.

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53
Q

Common ACE inhibitor drugs?

A

All end in -pril!

  • lisinopril (Zestril, Prinivil) GO TO CHOICE
  • captopril (Capoten)
  • enalapril (Vasotec)
  • quinapril (Accupril)
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54
Q

Why are ACE inhibitors good for kidneys?

A

The increase blood flow through the kidney by dilating the efferent arteriole.
e=exit (efferent)

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55
Q

ACE inhibitors are used to treat?

A

HTN - one of the first line choices in CKD and DM patients!

-CHF

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56
Q

What is the “usual” dosing for ACE inhibitors?

A

Once daily (90%), sometimes BID.

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57
Q

What labs must be monitored with ACE inhibitors?

A

-serum potassium and creatinine 4 WEEKS of initiation or dose increase.

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58
Q

What lab value(s) might you see an increase in after beginning ACE tx or increasing dose?

A

Serum K+ and creatinine.

40% is not normal.

59
Q

What should you advise the patient to watch in their diet when taking ACE inhibitors?

A

Dietary potassium intake.

60
Q

Adverse effects of ACE inhibitors?

A
  • COUGH!!!!
  • angioedema
  • hyperkalemia, especially in CKD and DM patients.
  • acute renal failure
  • neutropenia
61
Q

ACE inhibitors contraindications

A
  • Pregnancy category C/D
  • Angioedema when taken with other ACE inhibitors
  • RENAL ARTERY STENOSIS
62
Q

What drug class is contraindicated in renal artery stenosis?

A

ACE inhibitors

63
Q

ACE inhibitor drug interactions

A
  • potassium supplements
  • potassium sparing diuretics
  • NSAIDS (can increase BP) and are harmful to the kidney due to prostaglandin dilation of afferent tubules. Blood pools in kidney.
64
Q

ACE inhibitors + NSAIDS

A

Bad drug interaction! Harms the kidney!

65
Q

All of the ACE inhibitors can be dosed once EXCEPT for

A

Captopril. Dosed BID to TID. Because of this, is used infrequently. Also needs to be taken on an empty stomach?

66
Q

Which ACE inhibitor is a prodrug of enalaprilat?

A

Enalapril. Only available IV

67
Q

Which is the most commonly used ACE-I?

A

Lisinopril (Zestril, Prinivil)

Dose 10-40 mg daily

68
Q

Which ACE-I needs to be taken on an empty stomach?

A

Captopril. Absorption is decreased by 30-40% when given with food. Also needs multiple dosing.

69
Q

Angiotensin II Receptor Blockers

A

All end in -sartan

  • Irbesartan (Avapro)
  • Losartan (Cozaar)
  • Olmesartan (Benicar)
  • Valsartan (Diovan)
70
Q

Which ARB causes diarrhea?

A

Olmesartan (Benicar)

71
Q

ARBs MOA

A

Inhibits angiotensin II at its receptor sites.

-Does not inhibit breakdown of bradykinin!

72
Q

ARBs are used to treat

A

FIRST LINE OPTION FOR CKD!!

-CHF

73
Q

How often are ARBs dosed?

A

Often once daily

74
Q

Increased potassium and angioedema may be seen in

A

ARBs

75
Q 
Hypotension/orthostatic hypertension
-angioedema
-hyperkalemia
-dizziness
are all adverse effects of what drug class?
A

ARBs

76
Q

ARB contraindications

A
  • Pregnancy category C/D
  • Caution in patients with RENAL ARTERY STENOSIS
  • possible use in patients that have had prior angioedema with ACE. Use with caution.
77
Q

ARBs contraindications

A
  • potassium supplements
  • potassium sparing diuretics
  • NSAIDS
78
Q

What is a direct inhibitor of renin?

A

Aliskiren

79
Q

What are the two categories of Calcium Channel Blockers?

A
  1. Non-dihydropyridines

2. Dihydropyridines

80
Q

What drug classes are best choices for African Americans with HTN?

A

CCA

Thiazides

81
Q

What are the non-dihydropyridine drugs?

A
  • verapamil (Calan)
  • diltiazem (Cardizem, Cartia, Dilacor, Taztia)
    All of the above ARE NOT INTERCHANGABLE! Once patient is started on one kind, do not change!
82
Q

What are the dihydropyridine drugs?

A
  • amlodipine (Norvasc) most common
  • felodipine (Plendil)
  • isradipine (Dynacirc)
  • nifedipine (Adalat, Procardia)
83
Q

Role of Calcium Channels?

A

When channels are opened, calcium influx into smooth muscle, specifically:

  1. cardiac smooth muscle
  2. vascular smooth muscle
    - results in activation of intracellular Ca+ and ultimately leads to MUSCLE CONTRACTION (activates myosin and actin).
84
Q

CCB MOA

A
  • inhibits Ca+ influx into cells to PREVENT MUSCLE CONTRACTION
  • inhibition at cardiac smooth muscle
    decreases inotropy (force) and
    chronotropy (rate) of contraction
  • inhibition at vascular smooth muscle, which causes VASODILATION
85
Q

Why are CCBs not indicated in patients with CHF?

A

CCBs lower BP, and since CHF pts already have decreased contractile force, CCBs might increase CHF. **especially nondihydropyridines!

86
Q

Dihydropyridines MOA

A
  • inhibits Ca+ influx into VASCULAR SMOOTH MUSCLE
    As a result, EVERYTHING DILATES!!
    **Watch for possible pedal or tibial edema.
87
Q

Non-dihydropyridines MOA

A
  • inhibits Ca+ influx into CARDIAC SMOOTH MUSCLE. Result: decreased rate and force of contraction.
    CI in CHF!!
88
Q

Uses of CCB?

A

HTN. To induce smooth muscle dilation. Vascular and cardiac. Do not use in CHF.

89
Q

What drug can be used to treat SVT and afib?

A

Diltiazem and verapamil.

CCBs

90
Q

What drug(s) can be used for migrane prophylaxis?

A

Verapamil - CCB (can cross BBB)

Propranolol - beta blocker

91
Q

What CCB causes constipation?

A

Verapamil

92
Q

Hypotension is an adverse effect of?

A

All CCBs

93
Q

Constipation, bradycardia, exacerbation of COPD, heart block, and gingival hyperplasia are adverse reactions of what drug(s)?

A

Non-dihydropyridines

94
Q

What are some adverse effects of dihydropyridines?

A
  • peripheral edema (because it dilates vascular smooth muscle).
  • reflex tachycardia
  • flushing
  • headache
  • BP and pulse
95
Q

What CCB causes the worst peripheral edema?

A

Nifedipine

96
Q

Which dihyropyridines are ok to use in patients with CHF?

A
  • amlodipine
  • felodipine
  • isradipine
97
Q

Which CCB should you never use sublingually?

A

nifedipine (dihydropyridine). Causes severe hypotension, and increased risk for MI and death.

98
Q

Patients with isolated systolic HTN might benefit from what CCB?

A

Dihyropyridines (amlodipine, felodipine, isradipine, nifedipine)

99
Q

Soy and egg allergy are CI in this drug

A

Clevidipine (IV only)

100
Q

Verapimil DI

A
  • P450 inhibitor

- metabolized by CYP450

101
Q

Which is not a potential adverse effect associated with furosemide therapy?

A

Hypercalcemia

102
Q

Perindopril is from what class?

A

ACE inhibitor

103
Q

Eprosartan belongs to what class?

A

ARBs

104
Q

Most common beta blockers

A
  • atenolol
  • metropolol succinate
  • metropolol tartate
105
Q

Drugs ending in -olol are most likely

A

Beta blockers

106
Q

Beta blockers are reserved for patients that have

A

significant cardiac Hx.

  • Heart failure
  • post MI
  • CAD
  • CKD
107
Q

Beta blocker MOA

A

block beta-1 receptors thus decreasing the effects of epinephrine and NE. Result is decreased BP and HR.

108
Q

Where are beta 1 receptors?

A

Think beta “ONE”

ONE heart. Receptors located in the heart.

109
Q

Beta 2 receptors are found where?

A

Think beta “TWO”
TWO lungs. Receptors located in the lungs.
Remember your beta 2 agonists, like albuterol.

110
Q

What are the four “groups” of beta blockers?

A
  • cardioselective
  • mixed a + b
  • ISA (intrinsic sympathomimetic activity)
  • non-specific
111
Q

Which drugs belong to the cardio selective group of beta blockers?

A 
- AMEBBA!!
A tenolol
M etropolol
E smolol
B ioprolol
B etaxaolol
A cebutolol
112
Q

Which beta blockers are beta -1 specific?

A

the AMEBBA drugs!

Cardio selective!

113
Q

Carvedilol and labetaolol belong to what class of b-blockers?

A

mixed alpha & beta

114
Q

This medication prevents sodium reabsorption in the distal tubule

A

Thiazide diuretics

115
Q

This medication class inhibits active transport of sodium, chloride and potassium in thick ascending limb of Loop of Henle, causing excretion of these ions

A

Loop diuretics

116
Q

This medication class competes with aldosterone, prevents sodium reabsorption and potassium excretion

A

Aldosterone receptor blockers

117
Q

This drug class inhibits the conversion of angiotensin I to angiotensin II

A

ACE-I

118
Q

Propanolol acts via this specific MOA

A

blocks beta 1 and beta 2 receptors

119
Q

This drug class is typically dosed at night

A

Alpha-1 blockers. Due to orthostatic hypotension

120
Q

Clonidine patch is changed this often

A

every 7 days

121
Q

Most ACE-I are dosed this way

A

Once daily

122
Q

Metropolol succinate is dosed how often

A

Once daily

123
Q

Name 3 drug classes that should be dosed in the morning

A
  • loops
  • thiazides
  • potassium sparing diuretics
124
Q

Name at least one drug class that you should not use during pregnancy

A

ACE-I and ARBs

125
Q

Which drug class do you NOT want to use in a patient with CHF

A

Nondihyropyridines

126
Q

Use precaution with these 2 drugs classes in patients with sulfa allergies

A

Loops

Thiazides

127
Q

Which drug classes would you want to avoid in patients with high potassium

A
  • potassium sparing diuretics
  • aldosterone antagonists
  • ACE-I
  • ARBs
128
Q

Which drug class do you NOT want to use in a patient with renal artery stenosis

A

ACE-I

129
Q

Describe how the electolytes are affected by HCTZ

A

K+ and Na+ decrease

Ca+ and uric acid increase

130
Q

This is the number one side effect of verapamil

A

Constipation

131
Q

This is the most common side effect of captopril

A

Dry cough

132
Q

Rebound HTN will occur with these 2 classes of medication if suddenly discontinued

A

Beta-blockers and clonidine

133
Q

Terazosin causes this side effect which is why it must be taken at bedtime

A

First dose hypertension

134
Q

Do not take salt substitutes with the 4 following drug classes

A

What are ACE-I, ARBs, and potassium sparing diuretics and aldosterone antagonists

135
Q

Report any angioedema with the following two drug classes

A

ACE-I

ARBs

136
Q

Counsel patients about peripheral edema with this class of medication

A

Dihydropyridines

137
Q

This class of medication does not inhibit the breakdown of bradykinin thus is much less likely to cause cough

A

ARBs

138
Q

Beta blockers will cause these symptoms when the drug is started but will subside within a few weeks

A

“beta blocker blues”

Fatigue, tired, depression, funny heart beat

139
Q

These are the first line drug classes to treat HTN in African American patients

A

CCBs and thiazides

140
Q

This beta blocker can be used to prevent migranes

A

propranolol

141
Q

If a patient needs HTN medication, what are the 3 options for starting therapy?

A
  1. start 1 drug and max the dose
  2. start 2 drugs and add on another prior
    to maxing the dose on the first drug
  3. start 2 drugs
142
Q

These are 2 good agents to use in pregnancy

A

Methyldopa

Labetalol

143
Q

Which 2 agents should NOT be combined with aliskiren and describe the reason why

A

ACE-I and ARBs

- Increased risk of renal dysfunction

144
Q

MOA of cholesterol absorption inhibitors

A

Selectively inhibits dietary and biliary cholesterol absorption in the intestine

  • decreases delivery of dietary cholesterol to the liver
  • depletes hepatic cholesterol stores
  • increases clearance from the blood
  • increases expression of LDL receptors

Pharm II - antihypertensive therapies (1 decks)

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