Exam 6 lecture 1 Flashcards
1st line agents for initiation of hypertension agents
Thiazides, CCBs, ACE inhibitors, ARBs
Did SPRINT trial include patients with diabetes?
no
Patients who can not take thiazides should take
CCBs or ACE/ARB
Are all 1st line combinations acceptable for HTN?
no
What are the preferred combinations for 1st line tx for HTN
ACE/CCB
ARB/CCB
ACE/Diuretic
ARB/Diuretic
What combo can we never do for 1st line tx for HTN
ACE/ARB
For a patient with HTN and a patient specific factor for stable ischemic heart disease what is 1st line therapy? What should be added next? And after that?
1st line- B blocker
next should be ACE/ARB
Additional needed- DHP CCB
For a patient with HTN and a patient specific factor for HFrEF, what drug should we avoid?
Non DHP CCB
For a patient with HTN and a patient specific factor for preserved ejection fraction with fluid overload what should we use to treat
Diuretics
For a patient with HTN and a patient specific factor for preserved ejection fraction with elevated BP what should we use to treat
ACEi/ARB
For a patient with HTN and a patient specific factor for preserved ejection fraction with elevated HR what should we use to treat
B blocker
For a patient with HTN and a patient specific factor for stage 1 or stage 2 CKD and albuminuria (>300mg.day) or >300mg/g-creatine ratio what should we use to treat
ACEi (Or ARB if no tolerance)
For a patient with HTN and a patient specific factor for CKD stage 3 or 4 treatment
ACEi (or ARB)
eGFR cut off for stage 3 or 4 CKD
<60
For a patient with HTN and a patient specific factor for post kidney transplant
DHP CCBs
when to initiate therapy for a patient with HTN and a patient specific factor for secondary CVD (stroke) prevention
> 140/90 BP
For a patient with HTN and a patient specific factor for secondary stroke (CVD) prevention what should treatment be
Thiazides (1st line)
ACe/ARB
Combo of the above
For a patient with HTN and a patient specific factor for diabetes patients
If albuminuria (>300 mg/day OR >300 mg/g albumin-to-creatine ratio >300 -ACE/ARB
If not- Thiazide or CCB
IMPORTANT For a patient with HTN and a patient specific factor for pregnancy how to tx
Methyldopa
Nifedipine
Labetalol
Pregnancy is CI in which HTN drugs
ACE/ARB
Direct renin inhibitors
For a patient with HTN and a patient specific factor for black people without CKD or HF treatment
Thiazide or CCB
2nd line- ACE/ARB
how to treat HTN pts with stable ischemic heart disease
ACEi/ARB and BB 1st line
CCB add if uncontrolled
How to treat HTN pts with HFrEF
ACEi/ARB, Diuretic BB(1st)
How to treat HTN pts with HFpEF
Diuretic 1st line (if symptomatic)
if persistent HTN, ACE or ARB
how to treat CKD if albuminuria present
ACE (ARB if no tolerance to ACE)
How to treat HTN in renal transplant pts
CCB
how to treat HTN for secondary stroke prevention
ONLY START IF BP >140/90
Thiazide, ACE or ARB
Combination
how to treat HTN for DM patients`
Any 1st line option
but ACEi/ARB if albuminuria present
How to treat HTN for black patients
Use thiazides or CCBs unless HF or CKD
how to treat HTN for pregnant patients
methyldopa, nifedipine, labetalol
What are the 2 K wasting diuretics
Thiazides and Loop diuretics
Thiazide drug names
Chlorthalidone, hydrochlorothiazide, Indapamide, Metolazone
Loop diuretic drug names
Furosemide, torsemide, bumetadine
What are the 2 K sparring diuretics
Aldosterone antagonist
K sparring diuretics
Aldosterone antagonist drug names
Spironolactone, eplerenone
K sparring drug names
Amiloride, Triamtrene
What are the antihypertensive effects of diuretics due to?
Initially a decrease in SV, but long term a decrease in PVR.
Most commonly used thiazide? Most potent thiazide?
HCTZ most common
Chlorthalidone most potent
In what CRCL are thiazides more effective than loop diuretics
CrCl>30
when to dose thiazides
Morning (Avoid nocturnal diuresis)
When are thiazides dosed?
All dosed once a day in the AM
CI of thiazides
sulfa allergy
Drug interaction with thiazides
Li toxicity
Adverse effects of thiazides
Hypokalemia, Hypomagnesia, Hypercalcemia, hyperuricemia
When are loop diuretics more effective than thiazide drugs
When CrCl<30
What do we mean by loop diuretics have a high ceiling dose response curve
May need higher doses in patients with severely reduced renal function. Switching to another loop diuretic or form PO to IV can help
Most commonly used loop diuretic
Firosemide
Loop diuretic that can be used in sulfa allergy
Ethacrynic acud
adverse effects of loop diuretics
Ototoxicity, hypomagnesimia, hypokalemia
Aldosterone antagonist drugs
Spironolactone, eplerenone
What drug is preferred in resistant HTN? adverse effect of this drug? WHat to replace it with
Spironolactone, Replace with eplerenone, gynecomastia develops in upto 10% of pts
NEVER INITIATE aldosterone antagonist if
K>5
When to hold or reduce spironolactone dose
K>5.5 or Scr increase by 25%
Adverse effcets of aldosterone antagonists
Hyperkalemia, Hyponatremia, gynecomastia
Drug i/a of aldosterone antagonists
ACE/ARB/Renin inhibitors/ NSAIDs
contraindications of eplerenone
Eplerenone-impaired renal function (CrCl<50 or Scr>2 for males >1.8 for female)
T2DM and proteinuria
name the K sparring diuretic drug name
Amidoride triamtrene
Use of AMidoride triamtrene? What side effects could it cause?
Used in combo with thiazide to combat hypokalemia. Could cause gout (uric acid increase) and hyperkalemia
most diuretics are dosed
1 or 2 times a day (thiazide once)
Diuretic monitoring paraneters
electrolyte and kidney function
Steps to monitoring diuretic
- Get baseline before starting therapy
- check 1-2 weeks after initiation (1 week for CKD pts and elderly pts)
- 3-4 weeks after initiation check again for loop diuretics and aldosterone antagonist
Check every 6-12 months
what diuretic is 1st line for resistant HTN patients
Spironolactone
