HTN Day 2

Question 1

Name the 2 categories of Calcium Channel Blockers (CCBs) & how they differ (general)

Answer 1

Non-dihydropyridines - centrally acting (heart)

Dihydropyridines - peripherally acting (vasculature)

Question 2

Name 2 examples of non-dihydropyridines

Answer 2

Verapamil

Diltiazem

Question 3

Name 4 examples of dihydropyridines

Answer 3

Amlodipine
Felodipine
Isradipine
Nifedipine

Question 4

What is the role of Calcium channels in general

Answer 4

When these channels open: Ca++ influx into smooth muscle; specifically cardiac smooth muscle, vascular smooth muscle (can happen in 1 or both areas)

Results in the activation of intracellular Ca++ leading to muscle contraction

Question 5

What is the MOA of Calcium channel BLOCKERS?

Answer 5

• Inhibits Ca++ influx into cells, prevents muscle contraction
• Inhibition at cardiac smooth muscle: decreases inotropy (force) and chronotropy (rate)
• Inhibition at vascular smooth muscle (vasodilation to dec. BP)

Question 6

What is the MOA of Dihydropyridines specifically? Result?

Answer 6

Inhibits calcium influx into VASCULAR smooth muscle –> peripheral vasodilation

Question 7

What is the MOA of Non-dihydropyridines specifically? Result?

Answer 7

Inhibits calcium influx into CARDIAC SMOOTH MUSCLE –> decreased rate & force of contraction

Question 8

• What is the place in therapy for CCBs?

- What are some other uses for diltiazem and verapamil specifically?

Answer 8

• One of the FIRST LINE options for HTN
• Diltiazem can be used supraventricular tachycardia & atrial fibrillation

Verapamil can be used supraventricular tachycardia & atrial fibrillation AND migraine prophylaxis

Question 9

What is a common adverse effect of ALL CCBs?

Answer 9

Hypotension

Question 10

What are some adverse reactions of NON-dihydropyridines? Specifically Verapamil?

Answer 10

• Bradycardia
• Exacerbation of CHF: already experiencing dec. force & rate w/ dz!!
• Heart block
• Gingival hyperplasia

-Constipation (Verapamil)

Question 11

What are some adverse reactions of DIHYDROPYRIDINES?

Answer 11

• Peripheral edema: (worst with nifedipine)
• Reflex tachycardia
• Flushing (d/t inc blood flow)
• Headache (d/t vasodilation; avoid w/ freq. migraines)

Question 12

Which 3 dihydropyridines are best to use in pts with CHF? How would you proceed with administering these meds?

Answer 12

Amlodipine, felodipine and isradipine are OK to use in pts with CHF

-want to start with a lower dose to see how they tolerate the meds as peripheral edema is DOSE-RELATED

Question 13

What is a contraindication for Nifedipine? Why?

Answer 13

Should not be prescribed sublingually: risk for severe hypotension, reported increase risk for M.I. and death

Question 14

What is a clinical pearl regarding dihydropyridines?

Answer 14

Useful for pts with isolated systolic hypertension (esp elderly)

Question 15

What is a contraindication for Clevidipine (an IV only dihydropyridine)?

Answer 15

Not for pts with soy or egg allergy

Question 16

What are some drug interactions with Verapamil?

Answer 16

Drugs that are also metabolized by CYP450 3A4 –> Verapamil is an inhibitor of this enzyme (would make [drug] inc)

Question 17

For what condition are alpha-1 blockers more commonly prescribed?

Answer 17

BPH

approved for HTN, not as commonly used & not as monotherapy

Question 18

Give 3 examples of alpha-1 blockers

Answer 18

Prazosin
Terazosin
Doxazosin

Question 19

What is the MOA of a-1 blockers?

Answer 19

COMPETITIVELY INHIBITS a-1 receptors in the periphery causing vasodilation

Question 20

What is the place in therapy for a-1 blockers?

Answer 20

Only as an ADJUNCT especially in males. Not to be used often.

Question 21

What are 2 a-1 blockers that are approved for BPH but not for HTN?

Answer 21

Tamsulosin

Alfuzosin

Question 22

What is the “first-dose” effect of a-1 blockers?

Counseling advice?

Answer 22

Significant orthostatic hypotension occurs with first dose and any subsequent dose titrations (d/t major vasodilation–> counsel pts on this point)
-Take at BEDTIME, get up very slowly from laying down –> sitting –> standing

Question 23

What are some other adverse effects of a-1 blockers?

Answer 23

• Orthostatic hypotension, dizziness, vertigo
• Reflex tachycardia (esp early on); not seen if also on a B-blocker, may worsen orthostatic effects
• Fatigue, vivid dreams, depression, dry mouth

Question 24

What is the recommended course of action when starting a-1 blockers?

Answer 24

Need to SLOWLY TITRATE the dose upward to give the pt’s body time to adjust to massive vasodilation

Question 25

What are the dose frequencies of the a-1 blockers?

Answer 25

Doxazosin: once daily Terazosin: 1-2 x daily Prazosin: 2-3 x daily

Question 26

How should you proceed if a pt on an a-1 blocker is considering a PD-5 inhibitor?

Answer 26

Although package insert does not state this, caution should be used with PD-5 inhibitors d/t risk of massive hypotension (more of a risk with nitro & PD-5 inhibitors)

Question 27

Give 2 examples of alpha-2 agonists

Answer 27

Methyldopa | Clonidine

Question 28

What is the MOA of a-2 agonists?

Answer 28

STIMULATES a-2 receptors in the brain & reduces sympathetic outflow --> dec in BP & peripheral vascular resistance -tricks brain into dec. a-2 production

Question 29

What is the place in therapy for methyldopa?

Answer 29

Limited use; GOOD IN PREGNANCY (cat B)

Question 30

What is the place in therapy for clonidine?

Answer 30

Often used for RESISTANT hypertension - Also for substance abuse treatment (opiate or alc. withdrawal & avoidance) - Adjunct in pain management or ADHD/ADD therapy in children

Question 31

What are some adverse effects of a-2 agonists?

Answer 31

- Orthostatic hypotension, dizziness - Fatigue, depression, sedation - Sodium & water retention - Rebound tachycardia & hypertension (if stopped abruptly)

Question 32

What are some adverse effects of methyldopa specifically?

Answer 32

- Liver toxicities | - Hemolytic anemia

Question 33

What are some adverse effects of clonidine specifically?

Answer 33

- Rash with patch - "Anti-cholinergic like" SEs: dry mouth, sedation, constipation, urinary retention --> not for BPH, eye conditions, urinary ret. (elderly)

Question 34

What is a clinical pearl of clonidine?

Answer 34

Available as a patch (Catapres) --> applied every 7 days | -Effects begin w/in 12-24 hrs and last UP TO 3 DAYS after removal

Question 35

Name 2 vasodilators

Answer 35

Hydralazine | Minoxidil

Question 36

What is the MOA for vasodilators?

Answer 36

Direct vasodilators, esp in ARTERIES & ARTERIOLES --> decreased systemic vascular resistance/ peripheral vasodilation

Question 37

What are some adverse effects of vasodilators?

Answer 37

- Reflex tachycardia (consider co-admin w/ B-Blockers if SEs can be tolerated) - Increase in RENIN as resp. to vasodilation (consider co-admin w/ diuretic) - Headache

Question 38

What are some adverse effects of Hydralazine specifically?

Answer 38

- Lupus-like syndrome (butterfly rash; d/c if this occurs) - Dermatitis - Drug fever - Peripheral neuropathy - Hepatitis -DO NOT CONFUSE w/ hydroxizine for pruritis & anxiety

Question 39

What is an adverse effect of Minoxidil specifically?

Answer 39

Hirsutism (ingredient in Rogaine)

Question 40

What are the 2 preferred drug combinations for treating HTN?

Answer 40

ACE-I or ARB + Thiazide | ACE-I or ARB + Dihydropyridine CCB

Question 41

What are 3 "acceptable" drug combinations for treating HTN?

Answer 41

- Depends on pt indications - CCB + Thiazide - Thiazide + K-sparing diuretic - B-blocker + diuretic or dihydropiridine CCB

Question 42

What are 4 OTC drugs that may induce HTN? -IMPORTANT to get a FULL med list from pt incl OTCs/ supplements

Answer 42

- NSAIDs (i.e. motrin, ibuprofen, naproxen) - Appetite suppressants (inc. metabolism & HR) - Caffeine - Pseudoephedrine (decongestant)

Question 43

Give examples of prescription drugs that may induce HTN?

Answer 43

- Corticosteroids - Excessive alcohol - ACTH - Amphetamines (ADD, ADHD tx) - Cyclosporine (immunosuppressant) - Estrogen - Thyroid hormone (in excess) could be s/p Levothyroxine - Duloxetine, Venlafaxine (antidepressants that inc N.E & serotonin) - Bevacizumab (eye conditions, colon Ca) - Erythropoietin (injection)

Question 44

Name 6 reasons that a pt may stop taking their meds

Answer 44

1. Cost 2. They think their condition is "cured" 3. Side effects (counsel them on what to expect and how long they last; which ones to call the PCP for) 4. They forget 5. Less access to healthcare 6. Lack of education about WHY they're taking this med & the consequences if they don't take it

Question 45

A 44 y.o pt has a BP of 155/86, HR 80bpm; BMI is 35.2, smokes 1 ppd & experiences freq stress -Lab findings: K4.9, SCr 1.2; fasting lipids: wnl What other lab finding would you want to know before prescribing an anti-HTN med?

Answer 45

CrCl level... should be >30 mL/min if HCTZ is to be considered

Question 46

A 44 y.o pt w/ a 4 yr h/o HTN & a 20-yr pack hx is admitted for CAP; she has hyperlipidemia, angina and CKD (CrCl 40mL/min); she takes HCTZ 25 mg/day & metoprolol tartrate 75 mg b.i.d; recent P readings: 163-167/88-108, with pulse 58-65 bpm What is the best treatment recommendation to control her HTN?

Answer 46

Add Losartan 50 mg/day & maintain both HCTZ & metoprolol (3 drug regiment d/t BP >160/100

Question 47

What is the optimal BP goal (according to ADA) for a diabetic pt?

Answer 47

<140/80

Question 48

a 32 y.o pregnant female is diagnosed w/ HTN BP 145/95 | Which meds would you recommend for her?

Answer 48

Lebetolol or Methyldopa

Question 49

A 75 y.o man with BPH & HTN takes metoprolol XL 100 mg daily, crestor 10 mg daily; d/t recent diagnosis with BPH, which medication could you add? Counseling points?

Answer 49

An a-1 blocker i.e. Tamsilosen: should be taken at night --> watch for 1st dose effect (orthostatic hypoTN), flushing, reflex tachycardia

Question 50

``` Which of the following drugs is NOT known to inc BP? A. Acetaminophen B. Amphetamines C. Ibuprofen D. Prednisone E. Pseudoephedrine ```

Answer 50

A. ACETAMINOPHEN B. Amphetamines C. Ibuprofen (NSAID) D. Prednisone (corticosteroid) E. Pseudoephedrine

Question 51

Which of the following diuretics has efficacy in pts with a CrCl

Answer 51

D. II & III ONLY A. I only B. III only C. I & II only E. I, II, & III

Question 52

Which of the following antihypertensives has the potential to cause hyperkalemia? I. Lisinopril II. Valsartan III. Bisoprolol A. I only B. III only C. I & II only D. II & III only E. I, II, & III

Answer 52

C. I & II ONLY (ACE-I, ARB) A. I only B. III only D. II & III only E. I, II, & III

Question 53

Your pt has developed a dry cough with the use of quinapril. Which of the following is an appropriate course of action? A. Nothing; this effect is self-limiting B. Add cough suppressant (dextromethorphan) C. D/C quinapril; start enalapril D. D/C quinapril; start irbesartan E. D/c quinapril; start metoprolol XL

Answer 53

D. D/C QUINAPRIL; START IRBESARTAN A. Nothing; this effect is self-limiting B. Add cough suppressant (dextromethorphan) C. D/C quinapril; start enalapril (ACE) E. D/c quinapril; start metoprolol XL (B-Blocker)

Question 54

A 62 y.o WM w/ recent BP readings of 142-148/80-82 has hypothyroidism & no other significant PMH. What would we do to treat this pt?

Answer 54

Nothing: goal is <150/90

Question 55

A 52 y.o WM w/ recent BP readings of 142-148/80-82 has hypothyroidism & no other significant PMH. What would we do to treat this pt?

Answer 55

Goal: < 140/90; Could start a thiazide diuretic, ACE-I, ARB, CCB

Question 56

A 52 y.o AAM w/ recent BP readings of 142-148/80-82 has hypothyroidism & no other significant PMH. What would we do to treat this pt?

Answer 56

Goal: <140/90; could start a thiazide diuretic or a CCB

Question 57

A 62 y.o WM w/ recent BP readings of 142-148/80-82 has hypothyroidism, DM & CKD. What are the 2 possible BP goals? What would we do to treat this pt?

Answer 57

JNC 8 goal: <140/80 D/t CKD & DM: ACE-I or ARB

Question 58

A 45 y.o WM w/ recent BP readings of 165-169/80-82 has hypothyroidism. What would we do to treat this pt?

Answer 58

Goal: 160. Pick 2: thiazide diuretic or CCB with | ACE-I or ARB

Question 59

A 55 y.o HF, comes in for a med. refill. PMH: hyperlipidemia, HTN. Taking lisinopril 10mg daily starting last week, also taking Ibuprofen (800 mg daily) for pain. Labs: high K+ (6), SrCr is 2.0 (baseline 0.9). What is causing the high K+? What is causing the SrCr inc? Is it normal? What do you do?

Answer 59

- ACE-I is causing high K+ (make sure she's not taking salt substitutes, otherwise may need to lower dose or switch med class) - ACE-I and Ibuprofen can inc. SrCr; it is normal to inc by 30% of baseline but this is >100% inc. -> switch to another drug class entirely e.g. CCB: Amlodipine 5mg

Question 60

Which medication class may cause peripheral edema?

Answer 60

Dihydropyridines

Question 61

Which medication should you counsel your pt to take at bedtime (HS)?

Answer 61

a-1 blockers

Question 62

Which 2 medication classes may cause rebound HTN if abrupt d/c?

Answer 62

Clonidine, B-Blockers

Question 63

Which 2 medications can be used for migraines as well as HTN?

Answer 63

Propranolol & verapimil

Question 64

Which medication class may worsen CHF?

Answer 64

Non-dihydropyridines