Drugs for Hypertension

Question 1

Initial Therapy

Answer 1

Based on age and race. Ca channel blockers, TD, and ACE/ARBS
Young: respond well to ACE inhibitors, ARBs, BB(not first line)
Black/older: Thiazide diuretics or Ca channel blockers
Kidney disease: ACE/ARB

Initial monotherapy: successful in pts with mild, primary HTN. Most improvement seen at half-standard dose.

Question 2

Initial Combination Therapy

Answer 2

Indicated for: BP is more than 20/10 above goal

Lots of fixed dose, combo products

Question 3

Bed Time vs. Morning

Answer 3

Average nocturnal BP = 15% lower than daytime
Failure of BP to fall by at least 10%: Non-dipping. Strong predictor of adverse CV events
Shifting at least 1 antihypertensive from day to night can restore BP dip and reduce overall BP

Question 4

BP Goals

Answer 4

General: under 130/80
Olds: under 130
Diabetes: under 130/80
Kidney Dz: under 130/80

Question 5

Diuretics Overview

Answer 5

3 types: Thiazide, Loop, and Potassium sparing
Each works in a different part of kidneys and have their own risks/benefits
Thiazide: mainstay of HTN
Loop: Edema conds
K sparing: HTN and other conds for modest effects

Question 6

Hydrochlorothiazide (HCTZ) Thiazide Diuretics

Answer 6

For HTN and edema
Blocks Na and Cl reabsorption in distal convoluted tubule
CONTRA: Severe renal impairment, sulfa allergy
ADR: Increase occurrences of gout via increase in Uric acid, Electrolyte disturbances (Hypo- kalemia, calcemia, natremia, magnesemia). Photosensitivity.
Diuresis begins in 2 hours, peaks at 4-6, persists for 12. Take in morning
Others: Chlorthalidone, Chlorothiazide, Indapamide, Metolazone

Question 7

Spironolactone and Eplerenone

Answer 7

HTN, Heart failure w/reduced EF, hyperaldosteronism, ascites d/t cirrhosis
Aldosterone receptor antagonist. Increases water excretion, spares K+
CONTRA: Hyperkalemia, Addison dz, severe renal impairment
ADR: Hyperkalemia, Gynecomastia (Usually with Spironolactone, switch to Eplerenone)

Question 8

Triamterne and Amiloride (K+ sparing Diuretics)

Answer 8

HTN and edema
Blocks Na channels in distal convoluted tubules (stops reabsorption)
CONTRA: Severe renal impairment, severe hepatic dz (triamterene only), hyperkalemia
ADR: Hyperkalemia

Question 9

Beta Blockers

Answer 9

Angina, post-MI, Heart failure, HTN
BOX: abrupt discontinuation can lead to ischemic heart dz and rebound HTN. Need to slowly reduce dose
Beta adrenergic receptor blockers. Decrease HR/contractility and suppresses release of Renin (RAAS)
CONTRA: 2/3 degree heart block, bradycardia
ADR: Bradycardia, Hypoglycemia and masking of hypoglycemia, withdrawal with abrupt discontinuation, initial depression/fatigue, bronchospasm

Question 10

Beta Blocker Examples

Answer 10

Metoprolol is most common (selective)
Metoprolol Tartrate (Lopressor): Dosed Bid
Metoprolol Succinate: Dosed QD
Non-selective: Carvedilol (Coreg) and Labetalol (Normodyne) Avoid in pts with airway dz

Question 11

Doxazosin, Prazosin, Terazosin

Answer 11

3rd line antihypertensive agent
Alpha1 antagonist: Vasodilator
ADR: Orthostatic Hypotension big time

Question 12

Clonidine

Answer 12

HTN, ADHD, Menopause
Central Alpha2 agonist
ADR: Bradycardia, hypotension. Withdrawal with abrupt discontinuation
Others: Methyldopa (pregnancy), Guanfacine (ADHD Intuniv)

Question 13

Hydralazine

Answer 13

3/4 line HTN
Arteriole Dilation. Dosed 3-4 times/day
ADR: reflex tachycardia, fluid retention

Question 14

Minoxidil

Answer 14

9th line agent for HTN and also baldness
BOX: cardiac effects (pericardial effusion)
Contra: Phenochromocytoma
ADR: Hypertrichosis

Question 15

Amlodipine

Dyhydropyridine CCB

Answer 15

Norvasc
others all end in -pine
HTN and angina
Ca channel blocker (vasodilator)
ADR: PERIPHERAL EDEMA, reflex tachycardia, flushing, dizzy, headache

Question 16

Non-dihydropyridine CCB

Diltiazem () and Verapamil

Answer 16

(Cardizem)
HTN, angina, a-fib/flutter, SVT
DOSE: not all interchangeable
CONTRA: severe LV dysfunction, hypotension, 2/3 degree AV block unless they got a pacemaker
ADR: Reduced CO, Bradycardia, headache, constipation
M/E: STRONG CYP 3A4 Inhibitors = Verapamil: 20-30% adjustment in Liver failure/cirrhosis. No adjustment for Diltiazem

Question 17

Lisinopril

Answer 17

HTN, Heart failure with reduced EF, STEMI
BOX: Fetal toxicity, don’t be using whilst pregnant
ACE Inhibitor (vasodilator)
CONTRA: angioedema w/previous ACE, use with aliskiren in DM, or sacubitril (neprilysin inhibitor)
ADR: dry/nonproductive cough, hyperkalemia, acute kidney injury, angioedema

Question 18

Losartan

Answer 18

HTN, Proteinuric CKD in diabetes
BOX: fetal toxicity
ARB
CONTRA: aliskiren in DM
ADR: Hyperkalemia, Acute kidney injury

Question 19

Aliskiren

Answer 19

HTN
Direct renal inhibitor
BOX: fetal toxicity
CONTRA: ACE or ARB use
ADR: Hyperkalemia