HTN & Diuretics

Question 1

ACE Inhibitors:

Answer 1

Drugs = Ramipril, Enalapril, Lisinopril
Check U&Es = Potassium & creatinine

+ Decrease vascular resistance
+ Dec. ECF volume, aldosterone
+ Glucose, insulin, diuretics, BB’s unaffected

• • • Bradykinin mediated = dry cough
• • • Angioedema, hyperkalaemia (dec. aldosterone)
• • • Dec. angiotensin = renal failure/renal stenosis
• • • Teratogenic = avoid in pregnancy!

Question 2

ARB

Answer 2

Drugs = Losartan, Candesartan

= 2nd choice in Afro-Carribean
= Liver prodrugs

+ Dec. aldosterone & minimal bradykinin effects

• Dec. aldosterone = hyperkalaemia
• Dec. angiotensin II = renal failure
• Teratogenic!

Question 3

CCBs

Answer 3

Drugs = Amplodipine
= >55 years or Afro-Carribean

= DHP –> Dec. calcium entry, vasodilation, dec. PR

• Reflex tachycardia, palpitations, headaches/flushing, peripheral oedema (dec. hydrostatic pressure)

Question 4

Thiazide Diuretics

Answer 4

Drugs = Bendroflumethazide
= >55 years or Afro-Carribean

+ Na/Cl inhibitor in DCT
+ Target NCC (sodium, chloride symporter)
+ INC. renal/urine salt excretion
+ Vasodilators, HF

• — Worsens pre-existing gout
• – Diabetics (inhibits insulin release = hypokalaemia)
• — Metabolic alkalosis

Question 5

Aldosterone Antagonist

Answer 5

Drugs = Spironolactone (K-sparing)
= Resistant HTN

+ INC in transcription of Na/K ATP-ase for K+ & Na+ in CT/CD
+ CT/CD = (Na = retained) and (K = dec)
+ Hyperaldosteronism

Question 6

Loop Diuretic

Answer 6

Drugs = Furosemide, Bumetanide, Torasemide

= In LOH, NKCC2 symporter reabsorbs Na+, K+ Cl-
= LD’s inhibit NKCC2 symporter
= Oedema (oncotic > hydrostatic), HF

+ Natriuresis & diuresis
+ DEC. in ECF & blood volume

• Volume depletion
• Weakness, dizziness, cramp
• Deafness (NKCC2 symporter)
• DEC. in K+, Mg, Ca2+
• Metabolic alkalosis

Question 7

You wish to start a 62 year old female on propranolol for migraine prophylaxis. She is quite an anxious lady and is keen to avoid taking medication if she possibly can. She asks you about the common adverse effects so that she can make an informed decision as to whether she would like to start treatment.

Which one is a common adverse effect of propranolol to discuss with your patient?

Answer 7

Fatigue

Question 8

Propranolol is an antagonist at which type of peripheral receptor?

Answer 8

Beta-adrenoceptor

Question 9

Bisoprolol is an antagonist at which type of peripheral receptor?

Answer 9

Beta 1-adrenoceptor

Question 10

Angiotensin receptor blocks (ARB’s) reduce the circulating levels of which adrenal hormone?

Answer 10

Aldosterone

Question 11

A 76 year old patient is on a rehalibilitation ward recovering from an ischemic stroke one week ago and placed on aspirin. He was started on amlodipine and ramipril for hypertension but has no other medical history and was taking no other drugs. Three days ago he developed swollen ankles and was started on frusemide. His electrocardiogram shows no evidence of heart failure but his electrolytes showed a low sodium and potassium with both urea and creatinine in the normal range.

Which drug is most likely to be responsible for the development of his swollen ankles?

Answer 11

Amlodipine (peripheral vasodilator)

Question 12

Where is the receptor for the diuretic spironolactone used in resistant forms of hypertension?

Answer 12

Steroid receptors based in cell cytoplasm

Question 13

High blood pressure is a major risk factor for which of the following conditions?

Answer 13

Heart failure

Question 14

Which ion channel or transport protein is inhibited by bendroflumethazide in the treatment of hypertension?

Answer 14

Na/Cl symporter

Question 15

A 46 year old Caucasian male with diabetes is diagnosed with mild hypertension. A decision is made to start him on ramipril and to up-titrate the dose gradually to achieve a target blood pressure of 140/90 mmHg.

Before prescribing ramipiril, which parameter is the most important to check in primary care?

Answer 15

Serum creatinine

Question 16

A 27 year old female is seen in the nephrology clinic. She has a past medical history of chronic kidney disease, focal segmental glomerulosclerosis and hypertension for which she is taking Ramipril 7.5mg daily. She mentions she is hoping to start a family soon and wonders whether her medication is suitable?

Which one option would best describe the advice you would give?

Answer 16

Stop ramipril and change to labetalol before conception

Question 17

A 58 year-old man is attending routine follow up appointment after starting lisinopril for the treatment of hypertension 5 months earlier. On questioning, you establish that he has been compliant with his medication and has had no significant problems. You decide to titrate up his dose but carry out a blood test before proceeding.

Select the most important parameter to check from the blood test before modifying the dose?

Answer 17

Serum potassium

Question 18

ACE inhibitors produce which of the following changes?

Answer 18

Increase bradykinin

Question 19

What change in atenolol would you expect in a patient with renal failure?

Answer 19

Increased plasma concentration

Question 20

Which drug is first choice in treating hypertension for a patient of Afro-Caribbean origin?

Answer 20

Amlodipine

Question 21

A 72 year old woman is admitted by her GP as she has not opened her bowels for 5 days. She denies any pain and feels well in herself. Her past medical history includes hypertension, osteoarthritis and hypercholesterolemia. Her blood chemistry shows Na 136 mmol/L (135-145), K 2.7 mmol/L (3.5-5), urea 4.2 mmol/L (3-7), creatinine 73 umol/L (60-125).

Which one of her 4 prescriptions shown below is most likely to cause the electrolyte disturbance?

Answer 21

Bendroflumethazide 2.5mg daily

Question 22

Which adverse effect is less likely with an angiotensin receptor blocker than with an ACE inhibitor?

Answer 22

Angioedema