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Therapeutics II > HTN tx > Flashcards

HTN tx Flashcards

1
Q

ALLHAT takeaways

A

-thiazides first line
-then CCB or ACE if cant take those
-most pt need more than one

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2
Q

First line HTN tx

A

-thiazide dieurtics
-if pt cant consider CCB or ACEi
-most pt gonna need combo

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3
Q

First line tx

A
  1. thiazides
    -CCBs
    -ACE/ARBs
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4
Q

Preferred combo therapy options

A

-ACEi/CCB
-ARB/CCB
-ACEi/diuretic
-ARB/diuretic
-honorable mention: CCB/diuretic

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5
Q

Patient specific factors

A

-stable ischemic heart disease
-Heart failure
-CKD
-Cerebrovascular Disease
-Diabetes
-Pregnancy
-Race

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6
Q

Stable Ischemic Heart Disease tx considerations

A

-Beta blockers to reduce CV events and anginal symptoms
-ACEi/ARBs to reduce MI, stroke, CVD
-Dihydropyridine CCBs if still uncontrolled

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7
Q

Heart failure tx considerations

A

-reduced ejection fraction (HFrEF guidelines)
-Preserved ejection fraction (HFpEF) guidelines

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8
Q

Reduced ejection HF tx guidelines

A

-ANRI + BB + mineralcorticoid antagonist + SGLT2 inhibitor
-may add loop for persistant fluid etc
-AVOID CCBs bc no clinical benefit/worse outcomes

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9
Q

Preserved ejection fraction (HFpEF) tx guidelines

A

-SGLT2 inhibitor
-may add loop for fluid
-may add mineralcorticoid antagonist or ARNI/ARB in some

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10
Q

When to add to HFrEF tx

A

-loop for fluid
-hydralazine + isosorbide if black pt still symptomatic
-ivabradine if resting HR over 70 on max BB
-Vericiguat (IV diuretic) for worsening HF in high risk

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11
Q

When to add to HFpEF tx

A

-loop for fluid
-MRA for all women* or men w EF <55-60% and fluid
-ARNI for women* and men w LVEF, ARB if intolerant/cost

-women all EFs, men w EF < 55-60%

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12
Q

CKD tx considerations

A

-stage 1 or 2 AND albuminuria OR stage 3+ give ACEi or ARB
-post kidney transplant give dihydropyridine CCBs due to improved GFR and kidney survival, reduces graft loss, maintains GFR (ACEi = anemia, hyperkalemia, lower GFR)

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13
Q

Cerebrovascular Disease tx considerations

A

-Secondary stroke prevention
-ACEi/ARB
-thiazide
-combo
-initiating tx for BP <140/90 usefullness unknown

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14
Q

Diabetes considerations

A

-all first-line
-ACEi or ARBs if albuminuria

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15
Q

Pregnancy considerations

A

-methyldopa
-nifedipine
-llabetalol
-AVOID: ACEi/ARBs and direct renin inhibitors

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16
Q

Race tx considerations

A

-black adults w/o HF or CKD, including diabetes, tx w thiazide diuretic or CCB
-better data for lowering BP

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17
Q

Stable Ischemic HD tx

A

-ACEi/ARB + BB
-add CCB if not controlled

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18
Q

CKD tx

A

-ACEi/ARB
-if stage 1+2 AND albuminuria
-or if stage 3+

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19
Q

Renal transplant tx

A

-CCB over ACEi

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20
Q

Secondary stroke prevention tx

A

-thiazide
-ACE/ARB
-combo
-only start if BP >/= 140/90

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21
Q

Diabetes tx

A

-any firstline
-ACE/ARB if albuminuria

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22
Q

Afib tx

A

-ARB for prevention

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23
Q

Aortic disease tx

A

-BB for survival

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24
Q

Black pt tx

A

-thiazide or CCB
-unless HF or CKD

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25
Q

Pregnancy tx

A

-methyldopa
-nifedipine
-labetolol

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26
Q

Albuminuria

A

> /= 300mg/day or >/= 300mg/g allbumin-to creatinine ratio
-use ACEi or ARB

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27
Q

Tx options

A

-diuretics
-Angiotensin inhibitors
-Calcium Channel Blockers
-Beta Blockers
-Direct Arterial Vasodilators
-A1 blockers
-Central a-2 AGONISTs

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28
Q

Diuretic anti-HTN effects

A

-initial: diuresis = reduce stroke volume = inc PVR
-chronic: stroke volume returns to normal = dec PVR below pretreatment levels

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29
Q

Diuretic classes for HTN

A

-thiazide
-loop
-aldosterone antagonists (MRAs)
-Potassium-Sparing

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30
Q

Thiazide Diuretic agents + dosing

A

-Chlorhtalidone 12.5-100mg
-Hydrochlorothiazide (HCTZ) 12.5-50mg
-Indapamide 1.25-5mg
-Metolazone 2.5-5mg

-all once daily

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31
Q

Thiazide diuretics

A

-first line
-more effective than loop if CrCl > 30 mL/min
-dose in morning to avoid night piss
-chlorothalidone most studied and more potent than HCTZ

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32
Q

Thiazide diuretic adverse events

A

-HYPOkalemia/magnesemia
-HYPERcalcemia/uricemia/glycemia/lipidemia
-sexual dysfunction
-inc TGs and cholesterol

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33
Q

Thiazide interactions

A

-lithium toxicity

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34
Q

Thiazide contraindications

A

-sulfa allergy
-anuria

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35
Q

Loop diuretic agents + dosing

A

-furosemide 20-80mg qd or BID
-Torsemide 2.5-10mg qd
-Bumetanide 0.5-2mg qd or BID

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36
Q

Loop diuretics for HTN tx

A

-NOT first line for HTN
-preferred in HF for sx management
-more effective than thiazide at CrCl < 30 ml/min
-high-ceiling, may need higher doses w reduced renal function or fluid overload, switch to another loop or form PO to IV
-dose in morning but some have BID dosing?

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37
Q

Loop diuretics adverse effects + contraindications

A

-HYPOkalemia/magnesemia/calcemia
-HYPERuricemia
-ototoxicity

-AVOID if sulfa allergy

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38
Q

Aldosterone Antagonists (MRAs) agents + dosing

A

-Spironolactone 12.5-100mg
-Eplerenone 50-100mg
-qd or BID (dose in morning or afternoon)
-hold/reduce dose if potassium>5.5 or SCr inc > 25%

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39
Q

Aldosterone Antagonists (MRAs)

A

-spironolactone preffered w RESISTANT HTN
-switch to eplerenone if gynecomastia (10%)
-do NOT initiate if potassium >5

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40
Q

Aldosterone antagonist (MRA) concerns adverse effects

A

-HYPERkalemia
-HYPOnatremia
-gynecomastia (spirinolactone)

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41
Q

Aldosterone Antagonist interactions + Contraindications

A

-ACE/ARBs/renin inhibitors/NSAIDs inc risk of HYPERkalmeia
-AVOID eplerenone in impaired renal function (CrCl<50ml/min or SCr >2 (males) or 1.8 (female)), T2DM, proteinuria
-AVOID potassium sparing diuretics

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42
Q

Potassium-Sparing Diuretic Agents + dosing

A

-amiloride 5-10mg
-triamterene 50-100mg

-qd or BID

43
Q

Potassium-Sparing diuretics

A

-minimal BP effects, use in combo w thiazide to minimize hypokalemia
-caution in pt w diabetes or CKD (GFR<45ml/min)
-dose in the morning to avoid nocturnal diuresis

44
Q

Potassium-sparing diuretic adverse effects

A

-HYPERkalemia
-inc uric acid
-HYPERglycemia
-caution in DM and CKD

45
Q

Diuretic monitoring

A

-electrolytes and renal function 3-4 weeks after initiation
-only loop and MRA

46
Q

Diuretic clinical pearls

A

-do not give a tbedtime
-thiazides first-line for most
-Spirinolactone is first-line for resistant HTN
-watch sulfa allergy
-check CrCl
-monitor potassium and electrolytes

47
Q

Angiotensin Inhibitors

A

-Angiotensin converting enzyme inhibitors (ACEi)
-Angiotensin II receptor Blockers (ARBs)
-Renin inhibitors

48
Q

Angiotensin Converting Enzyme Inhibitors (ACEi) mech

A

-inhibits angiotensin I to II conversion
-vasodilation
-reduced PVR
-inc diuresis

49
Q

ACEi benefits

A

-good for pt w h/o:
-DM w proteinuria
-post MI
-CKD
-good option for PM dosing to ensure BP dipping overnight

50
Q

ACEi agents + dosing

A

-BenazePRIL 10-40mg qd or BID
-Captopril 12.5-150mg BID or TID
-Enalapril 5-40mg qd or BID
-Fosinopril 10-40mg qd
-Lisinopril 10-40mg qd
-Moexipril 7.5-30mg qd or BID
-Perindopril 4-16mg qd
-Quinapril 10-80mg qd or BID
-Ramipril 2.5-10mg qd or BID
-Trandolapril 1-4mg qd

51
Q

ACEi adverse effects (pril)

A

-angioedema
-cough up to 20%
-HYPERkalemia
-acute renal failure w severe bilateral renal artery stenosis

52
Q

ACEi contraindications (pril)

A

-h/o angioedema on ACEi
-use of aliskiren in pt w DM
-pregnancy/breastfeeding

53
Q

Angiotensin II Receptor Blockers (ARBs)

A

-binds target to block angiotensin II blockers
-vasodilation
-reduce PVR
-inc diuresis

54
Q

ARBs

A

-first line tx option
-back up if ACEi not tolerated
-(doesnt block bradykinin breakdown = less cough)
-(can use w h/o angioedema from ACEi)
-good for PM dosing

55
Q

ARB agents + doising

A

-Azilsartan 40-80mg
-Candesartan 8-32mg
-Irbesartan 150-300mg
-Lostartan 50-100mg qd or BID!
-Omlesartan 20-40mg
-Telmisartan 20-80mg
-Valsartan 80-320mg

-all qd
-losartan qd or bid

56
Q

ARB adverse effects

A

-angioedema
-HYPERkalemia
-acute renal failure w severe bilateral renal artery stenosis

57
Q

ARB contraindications

A

-h/o angioedema on ARB
-use of aliskren in DM
-pregnany/breastfeeding

58
Q

ACEi/ARB monitoring

A

-Potassium and renal function 1-2 weeks after initiation in elderly
-3-4 weeks in low risk or potassium <4.5
-check at 3-4 weeks only needed is elevated SCr or potassium at 1-2 weeks
-consider holding/reducing dose if potassium >5.5 or SCr inc >30%

59
Q

Direct Renin Inhibitors

A

-aliskiren 150-300mg qd
-not first line (expensive and not better than ACE/ARB)
-less cough than ACEi
-avoid in pregnancy
-dont use w ACEi or ARB in DM

60
Q

Direct renin inhibitor monitoring (aliskren)

A

-Postassium
-BUN
-SCr

61
Q

Aliskiren (renin inhibitor) adverse effects

A

-diarrhea
-musculoskeletal effects (CK increase
-dizziness
-HA
-HYPERkalemia
-renal insufficiency/ARF
-orthostatic hypotension

62
Q

Angiotensin Inhibitor clinical pearls

A

-discuss contraceptive methods in younger women
-do not combine drug classes
-assess hyperkalemic risk (CKD, meds, etc)
-educate on dietay potassium (bananas, seasining)
ACEi/ARBs preferred over other first-line agents in presnce of other compelling indications

63
Q

Calcium Channel Blockers (CCB)

A

-inhibit influx of calcium across cardiac and smooth muscle cell membranes = coronary and peripheral vasodilation
-firstline

64
Q

CCB subclasses

A

-Dihydropyridines (more vasodilation)
-Nondihydropyridines (more negative ionotropic effects)

-overall similar effect on BP

65
Q

Dihydropyridine CCB agents + dosing

A

-Amlodipine 2.5-10mg qd
-Felodipine 5-20mg qd
-Isradipine 2.5-20mg BID
-Isradipine SR 5-20mg qd
-Nicradipine SR 30mg-120mg BID
-Nifedipine LA 30-120mg qd
-Nisoldipine 10-40mg qd

-Amlodipine and felodipine no ionotropic effects

66
Q

Dihydropyridine CCBs

A

-additional benefit in pt w Reynaud’s and elederly pt w isolated systolic HTN
-more potent vasodilators than nondihydropyridine CCBs
-vasodilation = baroreceptor mediated tachycardia
-no effect on AV node conduction
-avoid short-acting (IR nifedipine/nicardipine)

67
Q

Dihyropyridine CCB adverse effects (-dipines)

A

-reflec tachycardia
-flushing
-dizziness
-headache
-peripheral edema (dose related)
-gingival hyperplasia

68
Q

Dihyrdopyridine CCB warnings (-dipines)

A

-inc risk of angina/MI pt w obstructive coronary disease due to reflex tachycardia

69
Q

Dihydropyridine (-dipine) CCB interactions

A

-grapefruit juice
-CYP3A4 enzyme inducers/inhibitors

70
Q

Nondihydropyridine CCB agents

A

-Diltiazem ER 120-180mg start max 360-540mg qd or BID
-Verapamil ER 100-180mg start max 400-480mg qd or BID
-diff formulations w diff dosing

71
Q

Nondihydropyridine CCBs

A

-good for AFib
-good for pt w agina that cant take BB
-slows AV node conductino and decreases HR = NEG ionotropic effects
-extended release prefferred

72
Q

Nondihydropyridine CCBs adverse effects

A

-bradycardia
-headache
-dizziness
-AV node block
-systolic HF
-gingival hyperplasia
-constipation (worse in verapamil > diltiazem)

73
Q

Nondihydopyridine CCB interactions

A

-use of BB (inc risk of heart block)
-grapefruit juice
-CYP3A4 enzyme inducers/inhibitors

74
Q

Nondihydropyridine CCB contraindications

A

-heart block
-left ventricular dysfunction

75
Q

CCB clinical pearls

A

-no routine lab monitoring required
-check for drug interactions
-CCBs first line HTN
-peripheral edema dose-dependent
-ER preffered
-nondihydropyridine CCB formulations are NOT interchangable
-if CCB is needed in setting of HF, choose amlodipine

76
Q

CCB to use in heart failure

A

-amlodipine

77
Q

Cardioselective Beta Blocker agents + dosing

A

-Atenolol 25-100mg
-Betaxolol 5-20mg
-Bisoprolol 2.5-20mg
-Metoprolol Tartrate 50-450mg BID
-Metopolol succinate 25-400mg
-Nebivolol 5-40mg

-all qd except metoprolol tartrate BID
-Nebivolol is nitric oxide induced vasodilation

78
Q

Nonselevtive Beta Blocker agents + dosing

A

-Nadolol 40-320mg
-Propranolol IR 40-640mg BID
-Propranolol LA 80-640mg

-avoid in bronchospastic airway disease

79
Q

Intrinsic sympathomimetic activity (ISA) Beta blocker agents + dosing

A

-Acebutolol 100-800mg BID
-Penbutolol 10-40mg qd
-Pindolol 5-60mg BID

-AVOID in HF and IHD

80
Q

Mixed a/B Beta blocker agents + dosing

A

-Carvedilol 6.25-50mg BID
-Labetalol 100-800mg BID

81
Q

Beta blockers

A

-not firstline unless HF or CAD
-pt populations w extra benefit: tachyarrythmias, tremors, migraines, thyrotoxicosis
-dec HR + force of contraction = decrease CO
-avoid abrupt cessation

82
Q

BB subclasses

A

-cardioselective
-nonselective
-intrinsic sympathomimetic activity (ISA)
-mixed

83
Q

Beta blocker adverse effects

A

-bronchospasm
-bradycardia
-fatigue
-exercise intolerance
-depression
-can mask s/sx of hypoglycemia

84
Q

BB contraindications

A

-second or third degree heart block
-decompensated HF
-post-MI (ISA BBs only)
-severe bradycardia
-sick sinus syndrome

84
Q

Direct Arterial Vasodilator agents + dosing

A

-Hydralazine 40-300mg BID-QID
-Minoxidil 5-100mg qd-TID

-minoxidil more potent

84
Q

Beta blocker use caution in pt with:

A

-Peripheral artery disease (carvedilol preferred)
-reactive ariway disease (use selective BBs)

85
Q

Direct Arterial Vasodilators

A

-last-line
-reserved for pt w special indications or very difficult to control BP (severe CKD/hemodialysis)
-minoxidil more potent
-combo w diuretic and BB

86
Q

Direct arterial vasodilator. adverse effects

A

-palpitations
-tachycardia
-chest pain
-GI effects
-Headache
-hematologic dyscrasias
-hepatotoxicity
-lupus-like syndrome/rash (hydralazine)
-fluid retention
-hair growth (minoxidil)

87
Q

Minoxidil box warning

A

-may cause pericarditis and pericardial effusion that may progress to tamponade
-may inc oxygen demand and exacerbate angina pectoris
-max therapeutic doses of diuretic and 2 other anti-HTN should be used before adding this drug
-should be given w diuretic to minimize fluid gain AND a beta blocker

88
Q

Direct arterial vasodialtors caution with

A

-CVA
-Renal impairment
-CAD
-liver disease
-Systemic Lupus Erythematosus (SLE)

-CAD listed as contraindication for hydralazine

89
Q

a-1 blocker agents

A

-doxazosin
-prazosin
-terazosin

90
Q

a-1 blockers

A

-never first-line
-second-line for pt w concomitant BPH
-associated w orthostatic HYPOtension esp in elderly

91
Q

Central a-2 agonist agents

A

-clonidine (PO or patch)
-methyldopa 250-500mg BID
-gunafacine 0.5-2mg qd

92
Q

Central a-2 agonists

A

-last-line due to adverse effects
-avoid abrupt cessation due to rebound HTN
-methyldopa in pregnancy

93
Q

Central a-2 agonist adverse effects

A

-CNS depression
-Dizziness/fatigue
-anticholinergic effects
-bradycardia
-reflex tachycardia
-fluid retention

94
Q

Clonidine dosing (central a-2)

A

-PO: 0.1-0.2mg BID-TID (max 2.4mg/day)
-Patch: 0.1-0.3mg/24 hours (weekly and lower risk of rebound HTN)

95
Q

Clonidine clinical pearls

A

-SLOW titrating: half dose q2-3 days, wean BB several days prior to clonidine wean if applicable
-Oral to transdermal: over lap oral regimen 3-4 days
-Patch to oral: start oral no sooner than 8 hours after patch removal

96
Q

Oral to patch clonidine

A

-day 1: patch + 100% dose
-day 2: admin 50%
-day 3: 25%
-day 4: patch only

97
Q

Monitoring summary

A

-ACEi/ARBs: BUN/SCr, potassium
-CCBs: HR (non-dihysropyridine)
-Aldosterone ANTAgonists: BUN/SCr, potassium
-Other diuretics: BUN/SCr, electrolytes (K, Mg, Na), uric acid (thiazides))
-BB:HR

98
Q

What if patient is NOT at goal

A

-consider nighttime dosing of one anti-HTN rx
-assess adherance
-educate on lifestyle mods
-rule out white coat HTN
-d/c interfering substances
-Pt may have resistant HTN

99
Q

Resistant HTN

A

-failure to attain goal BP while adherent to regimen of 3+ meds at max dose (including diuretic) or when 4+ agents needed
-estimated 17% of HTN pt
-risk: age, obesity, CKD, DM, black
-rule out secondary causes of HTN

100
Q

Stepwide management of resistant HTN

A
  1. max lifestyle interventions and optimize 3-drug regimen (ACEi/ARB, CCB, diuretic)
  2. Sub optimized thiazide diuretic (chlorthalidone/indapamide)
  3. Add MRA (spirinolactone, eplerenone)
  4. Add BB if HR > 70 BPM, consider a-2 (clonidine patch or guanfacine at bedtime if BB contraindicated and/or HR < 70 bpm *diltiazem
  5. Add hydralazine
  6. Sub minoxidil for hydralazine
101
Q

De-escalating theraoy

A

-comorbidities that would impact drug choice?
-1st line vs 2nd line
-adverse effects
-can we stop abruptly

Therapeutics II (55 decks)

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