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Pharm N895 > Hypertension > Flashcards

Hypertension Flashcards

1
Q

Staging of BP: normal

A

<120/80

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2
Q

Staging of BP: prehypertension

A

120-135/80-89

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3
Q

Staging of BP:​ Stage I HTN

A

140-159/90-99

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4
Q

Staging of BP:​ Stage II HTN

A

>/= 160/100

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5
Q

BP target for >/=60yo

A

<150/90mmHg

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6
Q

BP target for <60yo

A

140/90 mmHg

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7
Q

BP targets for all adults w/CKD or DM

A

<140/90 mmHg

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8
Q

AHA/ASA position on higher BP targets for older adults?

A

Do not endorse

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9
Q

Recommended 1st line treatment for non black, all ages, +/- DM

A

thiazide, ACEi, ARB, CCB

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10
Q

Recommended 1st line treatment for Black +/- DM

A

thiazide, CCB

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11
Q

Recommended 1st line treatment for CKD, any race, +/- DM

A

ACEi, ARB

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12
Q

Why is HTN a risk for AAs?

A

not higher risk of mortality

higher risk of EOD

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13
Q

HTN mgmt guidelines: what if goal is not reached in 1mth?

A

Increase dose or add recommended drug

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14
Q

HTN mgmt guidelines: can ACEis and ARBs be used concomitantly?

A

No!

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15
Q

HTN mgmt guidelines: what if goal is not achieved w/2 drugs?

A

add and titrate 3rd recommended drug

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16
Q

HTN mgmt guidelines: what if goal is not achieved even w/3rd drug?

A
  • Consider referral to HTN specialist
  • Use drugs from other classes
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17
Q

Non first line HTN drugs

A
  • Loop diuretics
  • K-sparing diuretics including aldosterone receptor antagonists
  • Direct renin inhibitors
  • Central-acting alpha2 agonists
  • Beta-blockers including those with alpha-blocking or vasodilating effects*
  • Alpha-blockers**
  • Nitrates
  • Direct vasodilators
  • Peripherally-acting adrenergic antagonists
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18
Q

*Beta blocker vs. ARB study: outcome

A

Atenolol (Beta blocker) associated with increased risk of composite CV death, MI, stroke compared to Losartan (ARB)

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19
Q

Alpha blocker vs. Thiazide Diuretics study

A

Doxazosin associated with increased rate of cerebrovascular events, heart failure and composite CVD events

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20
Q

Thiazide-type diuretics: Agents

A
  • Microzide (hydrochlorothiazide)
  • Chlorthalidone
  • Indapamide
  • Zaroxolyn (metolazone)
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21
Q

Thiazide-type diuretics: MOA/PK

A

Early: depletes sodium stores by blocking Na/CL transporter in renal distal convoluted tubule –> decreases blood vol. & CO

Late: CO normalizes, systemic vasc. Resistance decreases

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22
Q

Thiazide-type diuretics: ADRs

A
  • Hyponatremia
  • Hypokalemia
  • Metabolic alk
  • Photosensitivity
  • Hyperuricemia
  • Hyperglycemia
  • Weakness
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23
Q

Thiazide-type diuretics​: monitor

A

electrolytes, BP, fluid status

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24
Q

Thiazide-type diuretics​:​ special considerations (e.g., renal impairment, possible allergies, dose timing)

A
  • *Less effective in setting of renal impairment
  • *Sulfa drug!
  • *counsel patient to avoid taking close to bedtime (or they will get up all night to pee!)
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25
Q

Loop diuretics: agents

A

Lasix (furosemide)

Demadex (torsemide)

Bumex (bumetanide)

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26
Q

Loop diuretics​: MOA

A

Block Na/K pump in renal loop of Henle

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27
Q

Loop diuretics: ADRs​

A
  • Hyponatremia
  • Hypokalemia
  • Hypomagnesemia
  • Dehydration
  • Hyperuricemia
  • Oxtotoxicity!
  • Photosens.
  • Rash
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28
Q

Loop diuretics: are they sulfa drugs?

A

All are sulfa drugs (EXCEPT Edecrin)

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29
Q

Loop Diuretics: PT counseling

A

* Counsel patients to avoid taking close to bedtime (or they will get up all night to pee!)

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30
Q

Loop diuretics: considerations for lasix, demadex, bumex

A

*Lasix-also available IV (2:1 conversion from PO)

*Demadex-CYP2C9 substrate

*Bumex-also available IV (1:1 conversion from PO)

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31
Q

Potassium Sparing diuretics: Agents

A

Aldactone (spironolactone)

Inspra (eplerenone, also CYP3A4 substrate)

Amiloride

Triamterene

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32
Q

Potassium Sparing diuretics: MOAs

A
  • Aldosterone receptor antagonist (aldactone & eperenone)
  • Epithelial sodium channel blocker (amiloride, triameterene)
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33
Q

Potassium Sparing diuretics: ADRs

A

Hyponatermia

Hyperkalemia

Gynecomastia (spironolactone)

Amiloride & Triamterene

Hyponatremia

Hyperkalemia

Metabolic acidosis

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34
Q

Special considerations: aldactone

A

aldosterone antagonist

(K+ sparing)

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35
Q

Special considerations: Eplerenone

A

aldost. antag. CYP3A4 substrate

(K+ sparing)

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36
Q

Angiotensin-converting enzyme inhibitor (ACEI): Agents

A
  • Capotan (captropril)
  • Accupril (quinapril)
  • Prinivil (lisinopril)
  • Alface (rarripril)
  • Lotensin (benezapril)
  • Vasotec (enalapril, enalaprilaf)
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37
Q

ACEi: MOA

A

Prevent conversion of angiotensin I > angiotensin II, thereby inhibiting angiotensin II induced vasoconstriction and aldosterone secretion

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38
Q

ACEi: ADRs

A
  • Hyperkalemia
  • Dry cough
  • Angioedema
  • Rash
  • Dysgeusia
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39
Q

ACEis: metabolism

A

*most oral forms are pro-drugs requiring hepatic activation through hydrolysis

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40
Q

ACEis and AAs

A

* AA’s diminished efficacy increased risk for angioedema

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41
Q

ACEis and pregnancy

A

avoid in pregnancy, women of childbearing potential

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42
Q

ACEi: cough

A

*if dry cough occurs, trial another ACEI or switch to ARBs (less associated with cough d/t lack of effects on bradykinin)

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43
Q

ACEi: what to do if angioedema

A

angioedema occurs, avoid all ACEI and ARBs

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44
Q

ACEi: what to do if kidney issues

A

* hold in setting of AKI, however have beneficial effect on CKD (dx stabilization and decreased proteinuria)

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45
Q

ACEi: what is important about captopril? (duration, SEs, PK)

A

short-acting; rare neutropenia, CYP2D6 substrate

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46
Q

ACEi: which is IV formulation

A

enalopril (Vasotec)

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47
Q

Angiotensin-receptor blockers (ARB): agents

A
  • Cozaar (losartan)
  • Diovan (valsartan)
  • Teveten (eprosartan)
  • Avapro (irbesartan)
  • Mcards (teimisartan)
  • Atacand (candesartan)
  • Benicar (oimesartan)
48
Q

ARBs: MOA

A

Blocks angiotensin receptor therby inhibiting vasoconstriction and aldosterone secretion

49
Q

ARBs: ADRs

A
  • Fatigue
  • Diarrhea
  • Hyperkalemia
  • Cough
  • Angioedema
50
Q

ARBs & AAs

A

AA’s diminished efficacy increased risk for angioedema

51
Q

ARBs: what to do if cough or angioedema assoc w/ACEi?

A

* not associated with cough

* avoid in pts with anaphylaxis or angioedema to ACEI less associated with cough & angioedema than ACEI

52
Q

ARBs and pregnancy

A

Contraindication in pregnancy

53
Q

ARBs: concomitant use w/ACEi or renin inhibitor?

A

increases risk of hypotension, hyperkalemia and renal dysfunction

54
Q

Losartan metabolism

A

CYP3A4 substrate; CYP2C9 substrate & inhibitor

(ARB)

55
Q

Irbesartan (Avapro): metabolism

A

CYP2C8 and CYP2C9 inhibitor

(ARB)

56
Q

Renin Inhibitors: Agents

A

Tekturna (Allskiren)

57
Q

Tekturna (Allskiren): MOA

A

Inhibits renin therapy reducing angiotensin I, II and aldosterone

(Renin Inhibitor)

58
Q

Tekturna (Allskiren): ADRs

A

Hyperkalemia

Diarrhea

(Renin Inhibitor)

59
Q

Tekturna (Aliskiren)​: and renal impairment, diabetes, pregnancy

A

*avoid in pts with renal impairment (CrCl <80 ml/min) diabetes, or pregnancy

60
Q

Sympathoplegic Central Acting: Agents

A

Clonidine, methyldopa

61
Q

Clonidine: MOA

A

Central alpha 2 agonist decreases sympathetic and increases parasympathetic tone à reduced perpheral vascular resistance, bradycardia and reduced CO

(Sympathoplegic Central Acting)

62
Q

Clonidine​: ADRs

A

Abrupt withdrawal can result in hypertensive crisis

63
Q

Sympathoplegic Central Acting: ADRs

A
  • Sedation
  • Depression
  • Xerostomia
  • Confusion
  • Dizziness
  • Hallucinations
  • Nausea/vomiting
  • Tinnitus
  • Diaphoresis
  • Sedation
  • Confusion
  • Nightmares (yuck!)
  • Depression
  • Vertigo
  • Hemolytic anemia
  • Hepatitis
  • Drug fever
64
Q

Methyldopa: MOA

A

Reduces peripheral vascular resistance

(Sympathoplegic Central Acting)

65
Q

Methyldopa​: special consideration

A

* primarily used in pregnancy

66
Q

Adrenoreceptor Antagonists: Agents

A

Beta Blockers

Alpha Blockers

67
Q

Adrenoreceptor Antagonists: BBs, agents

A
  • Inderal (propranolol)
  • Lopressor (metropolol)
  • Tenomin (atenolol)
  • Brevibloc (esmolol)
  • Coreg (carvedilol)
  • Transdate (labetalol)
  • Bystolic (nebivolol)
68
Q

BBs: MOA

A

Beta 1 antagonists reduce HR, myocardial contractility, peripheral vasc. Resistance, reduce renin release, some also have alpha-blocking effects (labetalol)

69
Q

BBs​: ADRs

A

Bradycardia

Bronchoconstriction (beta2 effects)

Contribute to hypoglycemia unawareness

Depression

Sexual dysfunction

70
Q

BBs​:​ efficacy

A

*Agents w/direct vasodilating properties or alpha-block effects may be more effective for hypertension

*Reduce mortality after MI, some in heart failure as well

71
Q

BBs​:​​ discontinuation

A

Result in tachycardia

72
Q

BBs: when to avoid

A

pts with depression, asthma

73
Q

BBs: dosing consideration - who to dose differently, which most effective for BP

A

*Chinese ancestry pts can require lower doses

usually ones w/alpha activity, like carvedilol, for BP

74
Q

BB most likely to have CNS effects

A

propanolol -lipophillic. most likely to have central effects!

(BB)

75
Q

BB that is Cardioselective

A

Atenolol, 1x daily PO

Esmolol, ultra-fast acting cont. IV infusion

76
Q

Coreg (Carvedilol): formulations

A

avail as extended-release tab (not 1:1 conversion)

(BB)

77
Q

Labetalol: formulations

A

available as extended-release tab, IV form

78
Q

What distinguishes Nebivolol MOA from other BBs?

A

Nebivolol, unlike other beta-blockers, also produces an endothelium-derived nitric oxide-dependent vasodilation resulting in a reduction of systemic vascular resistance.

79
Q

Alpha Blockers: Agents

A
  • Cardura (doxazosin)
  • Hytrin (terazosin)
  • Minipress (prazosin)
80
Q

Alpha Blockers: MOA

A

Alpha 1 receptor antagonists –> vasodilation of veins and arterioles resulting in decreased peripheral vasc. resistance

81
Q

Alpha Blockers: ADRs

A
  • Ortho. Hypotension
  • Dizziness
  • Fatigue
  • HA
  • Rare priapism
82
Q

Alpha Blockers:​ considerations in elderly

A

*Most associated with orthostatic hypotension—avoid in elderly!

83
Q

Alpha blockers: pt counseling

A

*Titrate slowly, give dose at bedtime, advise patient to get up slowly from bed

84
Q

Alpha blockers: other uses

A

Effective in tx of symptoms of BPH

85
Q

Alpha blocker that is CYP3A4 substrate; longer 1/2 (22hr)

A

Cardura (doxazosin)

(alpha blocker)

86
Q

Terazosin: dosing consideration

A

may need to divide dose q12h combat wearing off or peak related hypotension

(alpha blocker)

87
Q

Prazosin: dosing considerations & other use

A

short-acting; requires frequent dose admin. may be effective adjunct for PTSD-related nightmares

(alpha blocker)

88
Q

Vasodilators - CCBs: agents

A

CCB:

Dihydropyridine

Norvasc (amlodipine)

Sular (nisoldipine)

Adalat CC (Nifedipine)

Cardene (nicardipine)

Cleviprex (clevidipine)

NON-dihydropyridine

Cardizem (dilitiazem)

Veralan (verapamil)

89
Q

Dihydropyridine: MOA

A

Relax arterial smooth muscle resulting in peripheral vasodilation w/o significantly affecting cardiac rate or output

(Vasodilators: CCBs)

90
Q

Dihydropyridine: ADRs

A
  • Peripheral edema
  • Flush!
  • HA!
  • Dizziness

(Vasodilators: CCBs)

91
Q

Nifedipine for acute tx of hypertensive crisis?

A

*Avoid immediate-release rifedipine for acute tx of hypertensive crisis d/t increased risk of heart attack, stroke and death! Avoid Nifedipine SL.

(Vasodilators: CCBs, dihydropyridine)

92
Q

Vasodilators -CCB - NON-dihydropyridine: MOA

A
  • Non-selective antagonism of L-type CC results in relaxation of arterial smooth muscle and peripheral vasodilation as well as depression of myocardial contractility thru decreased conduction rate of sinoatrial node and slowing of AV conduction
  • *Inhibit P-glycoprotein and CYP450 isoenzymes

(Vasodilators: CCBs, dihydropyridine)

93
Q

Vasodilators -CCB - NON-dihydropyridine: ADRs

A

Bradycardia

Heart block

Constipation

Peripheral edema

94
Q

Vasodilators -CCB - NON-dihydropyridine:​ Avoid in

A

*Avoid in pts with heart failure secondary to systolic dysfunction d/t negative inotropic effects

*Increased risk of complete heart block when used in conjunction with beta-blockers

95
Q

Amlodipine, nisoldipine, Nifedipine, diltiazem: PK

A

CYP3A4 substrate

diltiazem is also 3A4 inhibitor

(Vasodilators: CCBs)

(diltiazem is dihydropyridine)

96
Q

Clevidipine: formulations

A

only IV, ultra-short acting

(Vasodilators: CCBs, dihydropyridine)

97
Q

*Verapamil: Formulations

A

-immediate sustained, extended-release and IV form. avail.(Vasodilators: CCBs, dihydropyridine)

98
Q

Vasodilators - direct-acting: Agents

A

Hydralazine, Minoxidil

99
Q

Hydralazine: MOA

A

Direct vasodilation of arterioles thru stimulation of nitric oxide release which results in decreased systemic resistance

(Vasodilators: direct-acting)

100
Q

Hydralazine: ADRs

A
  • Flush
  • HA
  • Dizziness
  • Reflex tachycardia
  • anorexia
  • Diaphoresis
  • Rare peripheral neuropathy
  • Drug fever

(Vasodilators: direct-acting)

101
Q

Hydralazine: Special considerations for Rxing - how and with whom

A
  • *Tachyphylaxis develops rapidly, more effective when used in combo with other agenst such as nitrates
  • *Can be particularly beneficial to AA pts with both HTN and heart failure

(Vasodilators: direct-acting)

102
Q

Minoxidil: MOA

A

Direct vasodilation of arterioles –> decreased systemic resistance

(Vasodilators: direct-acting)

103
Q

Minoxidil: ADRs

A
  • Flush
  • HA
  • Dizziness
  • ECG changes (T wave)
  • Peripheral edema
  • Pericardial effusion
  • Tachycardia
  • Hypertrichosis
  • Fluid retention

(Vasodilators: direct-acting)

104
Q

Minoxidil: Special considerations: administer with…, can exacerbate…

A
  • *must administer w. diuretic to prevent edema
  • *can exacerbate heart failure!

(Vasodilators: direct-acting)

105
Q

Vasodilators: Nitrates - agents

A

Nitroglycerin

Nitroprusside

106
Q

Nitrates: MOA

A

Cause vasodilation of both venous and arteriolar vessels: increase cardiac output by decreasing afterload

107
Q

Nitrates: ADRs

A
  • Flush
  • Tachycardia
  • Palpitations
  • Dizziness/HA
  • Methemoglobinemia (nitroprusside)
  • Delayed hypothyroidism (nitroprusside)
108
Q

Nitrates: C/Is

A

*Contraind. with PDE-5 inhibitors like Viagra (sildenafil)

(Vasodilator)

109
Q

Nitrates: longterm use

A

*Not appropriate for long term mgmt of HTN d/t rapid dev. of tolerance

*When used for angina-require 10-12 hr nitrate free interval to avoid tolerance

110
Q

Nitroglycerin: Indication

A

-used for tx of hypertensive emergency in pts w/o IV access

(Nitrates, Vasodilators)

111
Q

Nitroprusside: dosing concern

A

ultra short-acting; risk of cyanide toxicity with prolonged/high doses!

(Vasodilator, nitrate)

112
Q

Angioedema – absolute C/I

113
Q

Bronchospastic Dz: Absolute C/I

114
Q

Depression: absolute C/I

115
Q

Liver Dz: Absolute C/I

A

Methyldopa

116
Q

Pregnancy: Absolute C/I

117
Q

Second or Third Degree Heart Block: Absolute C/I

A

BB, Nondihydropyridine CCB

Pharm N895 (13 decks)

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