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Pharm II > HTN Day 2 > Flashcards

HTN Day 2 Flashcards

1
Q

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

A

Non-dihydropyridines - centrally acting (heart)

Dihydropyridines - peripherally acting (vasculature)

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2
Q

Name 2 examples of non-dihydropyridines

A

Verapamil

Diltiazem

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3
Q

Name 4 examples of dihydropyridines

A

Amlodipine
Felodipine
Isradipine
Nifedipine

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4
Q

What is the role of Calcium channels in general

A

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

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5
Q

What is the MOA of Calcium channel BLOCKERS?

A
  • 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)
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6
Q

What is the MOA of Dihydropyridines specifically? Result?

A

Inhibits calcium influx into VASCULAR smooth muscle –> peripheral vasodilation

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7
Q

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

A

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

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8
Q
  • What is the place in therapy for CCBs?

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

A
  • 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

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9
Q

What is a common adverse effect of ALL CCBs?

A

Hypotension

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10
Q

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

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

-Constipation (Verapamil)

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11
Q

What are some adverse reactions of DIHYDROPYRIDINES?

A
  • Peripheral edema: (worst with nifedipine)
  • Reflex tachycardia
  • Flushing (d/t inc blood flow)
  • Headache (d/t vasodilation; avoid w/ freq. migraines)
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12
Q

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

A

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

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13
Q

What is a contraindication for Nifedipine? Why?

A

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

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14
Q

What is a clinical pearl regarding dihydropyridines?

A

Useful for pts with isolated systolic hypertension (esp elderly)

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15
Q

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

A

Not for pts with soy or egg allergy

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16
Q

What are some drug interactions with Verapamil?

A

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

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17
Q

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

A

BPH

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

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18
Q

Give 3 examples of alpha-1 blockers

A

Prazosin
Terazosin
Doxazosin

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19
Q

What is the MOA of a-1 blockers?

A

COMPETITIVELY INHIBITS a-1 receptors in the periphery causing vasodilation

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20
Q

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

A

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

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21
Q

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

A

Tamsulosin

Alfuzosin

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22
Q

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

Counseling advice?

A

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

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23
Q

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

A
  • 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
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24
Q

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

A

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

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25
Q

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

A

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

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26
Q

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

A

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)

27
Q

Give 2 examples of alpha-2 agonists

A

Methyldopa

Clonidine

28
Q

What is the MOA of a-2 agonists?

A

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

29
Q

What is the place in therapy for methyldopa?

A

Limited use; GOOD IN PREGNANCY (cat B)

30
Q

What is the place in therapy for clonidine?

A

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
31
Q

What are some adverse effects of a-2 agonists?

A
  • Orthostatic hypotension, dizziness
  • Fatigue, depression, sedation
  • Sodium & water retention
  • Rebound tachycardia & hypertension (if stopped abruptly)
32
Q

What are some adverse effects of methyldopa specifically?

A
  • Liver toxicities

- Hemolytic anemia

33
Q

What are some adverse effects of clonidine specifically?

A
  • Rash with patch
  • “Anti-cholinergic like” SEs: dry mouth, sedation, constipation, urinary retention –> not for BPH, eye conditions, urinary ret. (elderly)
34
Q

What is a clinical pearl of clonidine?

A

Available as a patch (Catapres) –> applied every 7 days

-Effects begin w/in 12-24 hrs and last UP TO 3 DAYS after removal

35
Q

Name 2 vasodilators

A

Hydralazine

Minoxidil

36
Q

What is the MOA for vasodilators?

A

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

37
Q

What are some adverse effects of vasodilators?

A
  • 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
38
Q

What are some adverse effects of Hydralazine specifically?

A
  • Lupus-like syndrome (butterfly rash; d/c if this occurs)
  • Dermatitis
  • Drug fever
  • Peripheral neuropathy
  • Hepatitis

-DO NOT CONFUSE w/ hydroxizine for pruritis & anxiety

39
Q

What is an adverse effect of Minoxidil specifically?

A

Hirsutism (ingredient in Rogaine)

40
Q

What are the 2 preferred drug combinations for treating HTN?

A

ACE-I or ARB + Thiazide

ACE-I or ARB + Dihydropyridine CCB

41
Q

What are 3 “acceptable” drug combinations for treating HTN?

A
  • Depends on pt indications
  • CCB + Thiazide
  • Thiazide + K-sparing diuretic
  • B-blocker + diuretic or dihydropiridine CCB
42
Q

What are 4 OTC drugs that may induce HTN?

-IMPORTANT to get a FULL med list from pt incl OTCs/ supplements

A
  • NSAIDs (i.e. motrin, ibuprofen, naproxen)
  • Appetite suppressants (inc. metabolism & HR)
  • Caffeine
  • Pseudoephedrine (decongestant)
43
Q

Give examples of prescription drugs that may induce HTN?

A
  • 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)
44
Q

Name 6 reasons that a pt may stop taking their meds

A
  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
45
Q

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?

A

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

46
Q

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?

A

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

47
Q

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

A

<140/80

48
Q

a 32 y.o pregnant female is diagnosed w/ HTN BP 145/95

Which meds would you recommend for her?

A

Lebetolol or Methyldopa

49
Q

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?

A

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

50
Q 
Which of the following drugs is NOT known to inc BP?
A. Acetaminophen
B. Amphetamines
C. Ibuprofen
D. Prednisone
E. Pseudoephedrine
A

A. ACETAMINOPHEN

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

51
Q

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

A

D. II & III ONLY

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

52
Q

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

A

C. I & II ONLY (ACE-I, ARB)

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

53
Q

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

A

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)

54
Q

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?

A

Nothing: goal is <150/90

55
Q

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?

A

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

56
Q

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?

A

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

57
Q

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?

A

JNC 8 goal: <140/80

D/t CKD & DM: ACE-I or ARB

58
Q

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

A

Goal: 160. Pick 2: thiazide diuretic or CCB with

ACE-I or ARB

59
Q

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?

A
  • 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
60
Q

Which medication class may cause peripheral edema?

A

Dihydropyridines

61
Q

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

A

a-1 blockers

62
Q

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

A

Clonidine, B-Blockers

63
Q

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

A

Propranolol & verapimil

64
Q

Which medication class may worsen CHF?

A

Non-dihydropyridines

Pharm II (5 decks)

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