HTN Drugs Flashcards
Most common HTN patients
older women, blacks
Organs effected by HTN
Heart - heart failure Brain - aneurysm, hemorrhage, stroke Kidney - failure Eye - retinopathy
JNC8 guidelines for HTN therapy; goals
>60 = <150, <90
Drug classes used in HTN
Vasodilators CCBs SNS-altering RAAS inhibitors Diuretics
Vasodilator drugs
Minoxidil, diazoxide, hydralazine, nitroprusside, fenoldopam
Mechanism of minoxidil and diazoxide
Increase K+ ATPase = hyperpolarization
Fenoldopam; unique feature
Only IV arterial dilator to also increase renal perfusion
Hydralazine; unique SE
Lupus-like
Common vasodilator side effects
Reflex tachycardia - stimulation of baroreceptors by dropping BP Increased renin/RAAS - stimulation of kidney due to decreased perfusion
CCB drugs
Dihydropyridines - nifedipine, amlodipine Non-dihydropyridines - verapamil, diltiazem
Dihydropyridines vs non-dihydropyridines
Dihydropyridines = reflex tachycardia; do not effect heart Non-dihydropyridines = decrease AV node conduction = no tachycardia = decreased HR
CCB common SE
flushing, headache
CCB unique SE
Verapamil - constipation V>D>N - negative inotropic N - edema and refractoriness
Vasodilators; a specific use
Hypertensive crisis - BP >180/120 IV arterial dilators - fenoldopam, nitroprusside
How to treat hypertensive crisis
IV arterial dilators - fenoldopam and nitroprusside Gradual, titrated treatment - a big BP drop = ischemia and further organ damage
Organs and associated SNS receptors
Heart - B1 Lung - B2 Kidney - A1/B1 Arteriole - A1/B2 Venule - A2
non-specific alpha antagonists
phenoxybenzamine phentolamine
non-specific alpha antagonist side effects
Inhibit A2 = no NE reuptake = rebound HTN when stopping drug
A1 specific antagonists
Prazosin, terazosin, doxazosin
A1 selective antagonist side effects
First-pass effect -orthostatic hypotension/dizziness/syncope
How to avoid A1 selective antagonist side effects
Give first dose at night before bed
non-specific beta antagonists
Propranolol - B1 and B2
Effects of B1 block
Heart - decreased HR Kidney = decreased RAAS
Effects of B2 block
Lung = bronchospasm Liver/pancreas = hypoglycemia, inc TAG/dec HDL Arterioles = constriction
B1-selective antagonists
Metoprolol, atenolol -effect B2 at high doses
Preferred beta-blocker and why
Metoprolol and atenolol -Safe in = asthmatics, diabetics, peripheral arterial disease
beta-blocker SE
impotence, hypoglycemia, bradycardia, depression, excersise intolerance, inc TAGs and dec HDL
Mixed beta-blockers
Labetalol and cravedilol - B1 + B2 + A1
How to avoid vasodilator SE
Combination therapy w/ beta-blocker and diuretic
Central A2 agonists
Clonidine, Guanadine, methyldopa
Mechanism of central A2 agonists
Decrease SNS outflow and Increase PNS outflow
SE of central A2 agonists
Depression, Na/water retention, orthostatic hypotension, rebound hypertension
Methyldopa - unique SE
hepatitis and hemolytic anemia
Clonidine - unique SE
anticholinergic (Blind as a bat, dry as a bone, hot as a hare, etc.)
Neuronal/ganglionic A2 agonists
Reserpine, guanethidine, guanadril, Trimethaphan
Only ganglionic A2 agonist?
Trimethaphan
SE of neuronal/ganglionic A2 agonists
increased gastric secretions, diarrhea, Na/water retention, depression, orthostatic hypotension, bradycardia
Drug combined w/ A2 agonists?
Diuretics - to prevent fluid retention
K+ sparring diuretic
Amiloride
Diuretic SE
orthostatic hypotension, hypomagnesium/hypokalemia/hypocalcemia/hyposodium, hyperglycemia/hyperuricemia Photosensitivity and ototoxicity
How to treat african americans initially?
Start w/ diuretics - more effects in blacks than ACE inhibitors
Aldosterone antagonists
Spironolactone, eplerenone
SE of aldosterone antagonists
Hyperkalemia
Renin inhibitor
Aliskiren
AT2 receptor
Binds angiotensin II/III - opposite effects of AT1 antiinflammatory, vasodilatory, apopototic
Special effect of ACE inhibitors and aldosterone antagonists
Regress and prevent heart hypertrophy
ACE inhibitors
Captopril, lisinopril, enalapril
ARBs
Losartan
ACE inhibitors; unique SE
Angioedema (discontinue immediately), cough
ACE inhibitors; general SE
Hyperkalemia, neutropenia
What to monitor w/ ACE inhibitors?
K+ levels and serum creatinine
When are ACE inhibitors contraindicated
In patients w/ renal artery stenosis - bilateral or unilateral; will cause failure Pregnancy
ARB side effects
orthostatic hypotension, renal insufficiency, hyperkalemia
How fast do ARBs/ACE inhibitors work?
Take 6 weeks to reach max effect
SE of renin inhibitor
orthostatic hypotension, hyperkalemia
ARBs/ACE inhibitors and drug interactions; what to watch out for
NSAIDs - due to prostaglandins Hyperkalemia inducing drugs
An example of synergistic combo therapy involving ACE inhibitors/ARBs
Diuretics - decreased fluid retention = increased renin release by kidney for increased perfusion Diuretics + ACE/ARB combo = no renin release = more effective drop in BP
ACE inhibitors and race
not as effective in blacks; diuretics more effective
JNC7 vs JNC8
Removed lifestyle modification Added grading system based on importance of guideline Systemic literature review Added racial, CKD, and diabetic subgroups Altered goals of therapy for >60
JNC8 first line therapy recommendations
General population
- First line - ACEi, ARB, thiazide diuretics, CCB
Black
- First line - thiazide diuretics, CCB
Diabetic
- First line - thiazide diuretics, CCB, ACEi, ARB
CKD
- First line - ACEi, ARBs
JNC8 therapy strategy
First visit = 1 anti-HTN drug
If goal not met w/in a month = add a second drug or increase dose of first drug
If goal not met w/ 2 medications = add a third drug (titrate); do not use ACEi and ARB together (similar action)
If goal not met w/ 3 medications = refractory HTN
What to monitory w/ diuretic therapy
BP
BUN/creatinine
Electrolytes - K+, Mg, Ca
uric acid - mainly for thiazide
What to consider with ACEi therapy in blacks?
Angioedema - 2 to 4x higher
Diuretics show stronger effect
Which drugs are contraindicated w/ LVH
Hydralazine and minoxidil
Which anti-HTN can be used w/ pregnancy?
Avoid ACEi/ARBs
Use - methyldopa, beta-blockers, vasodilators
anti-HTN drugs in sexually active teens?
Avoid ACEi/ARBs
General Tx strategy
2 or more drugs are usually needed
Thiazide diuretic should be one of those drugs
