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Therapeutics > HTN - Thumar > Flashcards

HTN - Thumar Flashcards

1
Q

at what BP do you initiate txt for pts ≥60 y/o (w/o CKD or DM)?

A

BP ≥ 150/90mmHg

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2
Q

at what BP do you initiate txt for pts < 60 y/o (w/o CKD or DM)?

A

BP ≥ 140/90mmHg

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3
Q

at what BP do you initiate txt for pts ≥ 18 y/o w/CKD?

A

BP ≥ 140/90mmHg

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4
Q

at what BP do you initiate txt for pts ≥ 18 y/o w/DM?

A

BP ≥ 140/90mmHg

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5
Q

what is the BP goal for pts ≥60 y/o (w/o CKD or DM)?

A

< 150/90mmHg

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6
Q

what is the BP goal for pts < 60 y/o (w/o CKD or DM)?

A

BP < 140/90mmHg

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7
Q

what is the BP goal for pts ≥ 18 y/o w/CKD?

A

BP < 140/90mmHg

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8
Q

what is the BP goal for pts ≥ 18 y/o w/DM?

A

BP < 140/90mmHg

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9
Q

are beta-blockers still first-line for HTN?

A

no!

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10
Q

chlorthalidone vs amlodipine vs lisinopril

A

No clear difference b/w single agent regarding fatal CAD and nonfatal MI

Chlorthalidone may be preferable (thiazide diuretic)
-HCTZ largely used in US – drug cost, availability, assumption of class effect among thiazides

Chlorthalidone used more in elderly population

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11
Q

hierarchy for HTN txt

A

CKD > race > co-morbidities

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12
Q

If pt has CKD (+/- DM, regardless of race), what meds do you treat HTN with?

A

ACEI or ARB

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13
Q

Black population (+/- DM; w/o CKD), what meds do you treat HTN with?

A

Thiazide or CCB

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14
Q

General population (non-block; +/- DM; w/o CKD), what meds do you treat HTN with?

A

Thiazide or CCB or ACEI or ARB

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15
Q

what do ACEI & ARBs treat and what are they shown to delay?

A

ACEI & ARBs treat <b>HTN</b> and are shown to <b>delay the progression of CKD</b>

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16
Q

what are the CrCl qualifications for Thiazides?

A

Less effective/ineffective in GFR < 30

-if Cr <30, they have CKD -> use ACEI or ARB

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17
Q

what is the definition of CKD?

A

abnormalities of kidney structure (GFR) or function, present for > 3 months, with implications for health

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18
Q

what is CKD classified by?

A

CKD is classified based on cause, GFR category, and albuminuria category

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19
Q

how many stages of CKD are there?

A

5 stages

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20
Q

at what stage is end stage renal dysfunction?

A

stage 5

higher the stage = more severe CKD

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21
Q

what are CKD stage 1-2?

A

GFR > 60 ml/min for > 3 months plus one or more markers of kidney damage <b>(albuminuria)</b>

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22
Q

what are CKD stage 3-5?

A

GFR < 60 ml/min for > 3 months

<b><i>-Don’t need to have measure of albuminuria for stage 2-5</i></b>

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23
Q

what should be considered obtaining for all pts with HTN and/or DM?

A

consider obtaining baseline and yearly albumin assessment for all pts with HTN and/or DM

(both HTN and DM are linked to CKD progression)

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24
Q

what is a common lab to order for HTN and/or DM patients?

A

“albumin-creatinine ratio”; “ACR”

  • “microalbumin/urine creatinine ratio”
  • **NOT serum creatinine
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25
Q

what is a normal ACR? (albumin-creatinine ratio)

A

normal < 30mg/g

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26
Q

what is a moderate increase (previously “microalbuminuria”) in ACR? if have DM at increased risk of?

A

30-300mg/g

If have DM, at increased risk of nephropathy, retinopathy, neuropathy

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27
Q

what is a severe increase (previously “macroalbuminuria”) in ACR? if have DM at increased risk of?

A

> 300mg/g

If have DM, at increased risk of MI, stroke

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28
Q

what medications can be used to decrease albuminuria in pt with CKD? why would you be on an ACEI or ARB w/out HTN? secondary effect of ACEI or ARB w/out HTN?

A

ACEIs or ARBs

  • Can have CKD w/out HTN and be on an ACEI or an ARB b/c ACEI/ARB are helping the CKD
  • Secondary effect may be BP lowering that you might not even want
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29
Q

what other medications besides ACEIs or ARBs also decrease albuminuria?

A

SGLT-2’s (specifically empagaflozin)

  • Can delay CKD progression in DM patients
  • Great txt option for patient with angioedema & has DM

Liraglutide delays CKD progression

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30
Q

what medication is a great option to delay CKD and for pts with angioedema & has DM?

A

SGLT-2’s (specifically empagaflozin)

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31
Q

why don’t ACEIs or ARBs work well for AA’s? What txt approach is preferable for them?

A
  • Low plasma renin activity and increased sodium/fluid loading (high-volume HTN)
  • Means vasodilation & diuretics are preferable txt approach
32
Q

what is the black population w/HTN particularly responsive to?

A

Black population with HTN particularly responsive to sodium restriction and diuresis

33
Q

what meds have better efficacy as monotherapy for Blacks w/HTN? what are these meds most effective in improving? what have some studies shown about ACEIs as mono therapy in Blacks w/HTN?

A
  • Thiazide diuretics and CCBs have better efficacy as monotherapy
  • Most effective in improving cerebrovascular, heart failure, and combined CV outcomes
  • Some studies have shown an increase in stroke risk with ACEIs in this populations (as monotherapy)
34
Q

when can you consider starting with dual therapy for HTN?

A

Can consider starting with dual therapy if BP is >20/>10mHg above goal at diagnosis

Both SBP & DBP need to be above goal by >20/>10

35
Q

if BP goal isn’t reached within one month of initiating txt, what can you do?

A

Increase/maximize dose of the initial drug OR

  • Add a second agent from a different class (Thiazide-type, ACEI/ARB, CCB)
  • (regardless of race; no longer “mono”therapy)
36
Q

what should you monitor for patients?

A

monitor labs as appropriate for chosen meds -> <b>get CMP</b>

37
Q

what should you recommend to your patient to keep?

A

a BP diary

38
Q

what else should you consider with your patient when treating their HTN?

A
  • Consider dietary/lifestyle interventions as appropriate
  • Respect cultural sensitivities, lifestyles, and beliefs
  • Smoking cessation has a huge impact on HTN -> decreases BP
39
Q

in the accomplish study, what did they show?

A
  • *Benazepril/amlodipine&raquo_space; benazepril/HCTZ
  • Significantly less CV mortality
  • ACEI plus CCB showed superiority versus ACEI plus thiazide

-These were also single pills (increased adherence and less cost)

40
Q

what did the accomplish study suggest that you should consider when treating HTN?

A

Consider ACEI + CCB over ACEI + thiazide

41
Q

if goal BP is not achieved with 2 agents, what can you do?

A

Add a third recommended agent; maximize doses

  • Avoid using ACEI and ARB in combination
  • Too potent hyperkalemic effect and too much impact on kidney injury
42
Q

if goal BP can’t be reached using a 3rd drug, what can you consider doing?

A
  • Ensure dose optimization and proper BP measurement techniques; consider secondary HTN work-up
  • Consider aldosterone-antagonist, beta-blocker, alpha-blocker, etc. due to resistant HTN
  • Consider referral to a HTN specialist
43
Q

what is a big barrier to HTN management?

A

COMPLIANCE!!!

-need to confirm that pts are picking up/taking their meds

44
Q

what meds are for primary prevention of HTN based on ASCVD risk profile?

A

anti-platelets; statins

45
Q

what are is age cutoffs range for elderly?

A

60-80 years or older

46
Q

when treating elderly for HTN, what meds showed favorable data?

A

low-dose thiazide diuretics

some data for DHP CCBs & ACEIs

47
Q

what must you consider for elderly when treating their HTN?

A

consider fall risk; hypo perfusion if BP goes too low

48
Q

what meds is there a limited role of in younger/women of child-bearing age?

A

ACEIs/ARBs; also statins

-unless contraception is in place and monitoring

49
Q

what should all women of child-bearing age be taking?

A

MVI + folic acid

50
Q

what are first-line HTN meds for pregnancy? second line?

A

first line = methyldopa; labetalol

second line = nifedipine (non-DHP); verapamil
-alternative -> clonidine

51
Q

role of what in pts with post-MI, HF, stroke?

A

BBs, anti-platelets, statins, anticoags

52
Q

what about treating HTN in osteoporosis pts?

A

MONITOR Ca

  • Thiazides -> increase Ca in blood (hypercalcemia)
  • Diuretics have volume depleting
  • Loops cause hypocalcemia (doesn’t mean you shouldn’t use loop b/c if have HF will need a loop)
53
Q

what HTN meds have sulfa component?

A

Thiazides and loops

54
Q

if have sulfa anaphylaxis allergy what should you do?

A

stay away from thiazides and loops

-use K-sparing diuretics or Ethycrinic acid

55
Q

what do all diuretics do to uric acid levels and gout?

A

all diuretics can cause hyperuricemia (increase uric acid levels)

56
Q

what about treating BPH & HTN?

A

alpha-1 blockers dual benefit for lowering BP & BPH

57
Q

what are the 7 simple tips to get an accurate BP reading?

A
  1. Support arm at heart level
    - Unsupported adds 10mmHg
  2. Put cuff on bare arm
    - Cuff over clothing adds 10-40mmHg
  3. Don’t have a conversation
    - Talking adds 10-15mmHg
  4. Empty bladder first
    - Full bladder adds 10-15mmHg
  5. Support back
    - Unsupported back adds 5-10mmHg
  6. Keep legs uncrossed
    - Crossed legs add 2-8mmHg
  7. Support feet
    - Unsupported feet add 5-10mmHg
58
Q

considerations for treatment-resistant pts?

A

<b>COMPLIANCE!! Dose-optimiation!!</b>

Combination agents

  • consider costs, available doses, and dosing
  • reduce pill burden and increase adherence

“Chronotherapeutics”

59
Q

how do you improve a pts adherence to HTN medication?

A
  • Assess patient understanding of disease and treatments
  • Use adherence aids such as charts or pill boxes
  • Link medication use with daily activities
  • Provide multi-disciplinary support
  • Recognize socio-behavioral issues
  • Simplify medication regimens
60
Q

what is chronotherapeutics?

A

consider administering one BP med at night (change one BP med that’s taken in the morning to taking it in the evening)

  • better 24hr control; possibly less dizziness
  • do not use diuretic in evening (b/c will make you pee a lot)
61
Q

what does recent data suggest about nighttime elevated BP?

A

that nighttime elevated BP correlates more closely with CV than does daytime BP

62
Q

what is there a concern for with chronotherapeutics?

A

loss of adherence & nocturnal hypotension

63
Q

what lifestyle modifications are there for HTN?

A
  • weight reducing (BMI index of 18.5-24.9 should be maintained)
  • Adopt DASH eating plan
  • Dietary sodium reduction
  • Physical activity
  • Moderation of alcohol consumption (no more than 2 drinks/day in men & no more than 1 drink/day in women)
64
Q

what is resistant HTN?

A

Blood pressure that remains above goal despite the concurrent use of 3 antihypertensive agents of different classes at optimal doses

65
Q

what is a common secondary cause of resistant HTN?

A

pseudoresistance, which can be due to several situations:

  • faulty BP measurement technique
  • white coat HTN; aggravation
  • NON-ADHERENCE!!! (MOST COMMON CAUSE)
66
Q

what are common causes of secondary causes of resistant HTN?

A

-Obstructive sleep apnea
-Primary aldosteronism
-Advanced CKD
-Renal artery stenosis
-Volume overload
-Excess alcohol intake
-Obesity
<b>-Medications*</b>

67
Q

what are uncommon causes of secondary causes of resistant HTN?

A
  • Pheochromocytoma
  • Cushing’s disease
  • Hyperparathyroidism
  • Intracranial tumor
68
Q

what drugs can induce HTN?

A

NSAIDs; COX-2 inhibitors; vasoconstrictors; stimulations; cocaine; other illicit drugs

sympathomimetics (decongestants, diet pills)

OCPs

Cyclosporine; tacrolimus; steroids

erythropoietin

natural licorice; herbals (ephedra, bitter orange)

69
Q

do updated guidelines recommend specific agents for pts with resistant HTN (already on 3 meds)?

A

NO!!!

70
Q

what other diuretics can you consider adding on to regimen for pt with resistant HTN?

A

K-sparing diuretics

-spironolactone (dear SBP 5-20mmHg, decr DBP 5-10mmHg & improve left ventricular size)

71
Q

what must you monitor K-sparing diuretics for?

A

monitor potassium b/c cause hyperkalemia

  • also consider impact of other medications on K
  • if pt has hyperkalemia at dx of HTN, may not be able to start K-sparing diuretic
72
Q

what is the dosing for spironolactone, eplerenone, amiloride?

A

spironolactone: 12.5-50mg daily
eplerenone: 50mg BID
amiloride: 2.5-10mg daily

73
Q

if pt does not have BB as part of their regiment, when should you consider their use?

A

if resting HR >80bpm

74
Q

which beta-blockers should you consider using for resistant HTN?

A

carvedilol/labetalol

-don’t have strong BP reducing effect

75
Q

when should BBs already be a part of a pts regimen?

A

if they have CHF or CVD

76
Q

when can alpha-1 blockers be considered for resistant HTN?

A

if pt has low HR and/or BPH

77
Q

what meds that are not commonly used to treat HTN due to adverse effect profile can be useful in resistant HTN?

A

clonidine, hydralazine, etc.

Therapeutics (6 decks)

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