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Clinical Pharmacology, Therapeutics & Principles of Prescribing > Hypertension, Heart Failure & Diuretics > Flashcards

Hypertension, Heart Failure & Diuretics Flashcards

1
Q

What is the clinical definition of hypertension?

A

BP taken in the clinic is over 140/90mmHg

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2
Q

What is the current NICE guidance of pharmacological therapy for hypertension?

A

ACE inhibitors/ ARBs

Calcium channel blockers

Diuretics

<55 years: A –> A + C–> A+C+D–> A+C+D+D or alpha blocker

>55 years, Afrocaribbean origin: C–> A+C–>A+C+D–> A+C+D+D or alpha blocker

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3
Q

What is the mechanism of action of ACE inhibitors in the treatment of hypertension?

Give some examples of such drugs

A

Reduction in AngII formation

Reduced vasoconstriction

Reduced salt/water retention

Reduced sympathetic activity

e.g. Lisinopril, Ramipril

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4
Q

What is the main side effect of ACE inhibitors?

List some other important side effects.

A

Main: dry cough

Others: angio-oedema, renal failure, hyperkalaemia

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5
Q

What is the mechanism of action of Angiotensin Receptor Blockers (ARBs)?

Why might this be used over ACE inhibitors?

A

Bind to the angiotensin AT1 receptor

Inhibit vasoconstriction and aldosterone stimulation caused by AngII

Less side effects that ACE inhibitors (no dry cough)

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6
Q

How do calcium channel blockers work to reduce hypertension?

A

Bind to specific alopha subunit of L-type calcium channel, reducing cellular calcium entry

Vasodilate peripheral, coronary and pulmonary arteries

Prolongs AP/ ERP

Reduction in cardiac preload and myocardial contractility (NOT good to HF patients)

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7
Q

What are the three main groups of calcium channel blocker?

What are they each most commonly used to treat?

A

Dihydropyridines - hypertension

Benzothiazepines- angina

Phenylalkylamines - rhythm disturbance

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8
Q

Give some examples of calcium channel blockers

A

Amlodipine

Verapamil

Diltiazem

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9
Q

How are thiazide/thiazide like diuretics helpful in the treatment of hypertension?

A

They reduce tubular sodium reabsorption

Reducing H20 reabsorption as a result

Blood volume decreases and then total peripheral resistance falls

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10
Q

Give some adverse effects of thiazide diuretics

A

Hypokalaemia

Increased urea and uric acid levels

Impaired glucose tolderance

Cholesterol and triglyceride levels increased

RAAS activatation (give with RAAS inhibitor)

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11
Q

Give an example of an angiotensin II receptor blocker

A

Azilsartan (Edarbi)

Candesartan (Atacand)

Eprosartan.

Irbesartan (Avapro)

Losartan (Cozaar)

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12
Q

Give an example of a K+ sparing diuretic

A

Amiloride

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13
Q

Give an example of an alpha-adrenoceptor blocker and briefly explain how it works to reduce BP

A

Doxazosin

Block alpha receptors and therefore antagonise the contractile effects of NA on vascular smooth muscle

Reduce peripheral resistance

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14
Q

Would alpha-blockers be safe to use in a patient with renal disease?

A

Yes

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15
Q

Give some adverse effects of alpha blockers

A

Postural hypotension

Headache, fatigue

Oedema

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16
Q

Give some exmples of drugs that block beta-adrenergic receptors and describe how they work to lower BP

A

Atenolol, bisoprolol, nebivolol

Block the effects of NA on beta-adrenergic receptors

Lower HR and cardiac output = Reduced myocardial oxygen demand

Inhibit renin release

Total peripheral resistance is reduced (rises initially)

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17
Q

Describe some of the adverse effects that may be experienced by a patients on beta-blockers

A

Lethargy, imparied concentration

Reduced exercise tolerance

Bradycardia

Raynaud’s

Imparied glucose tolerance

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18
Q

Aliskiren is an example of what kind of drug?

How does this work to reduce BP?

A

Direct renin inhibitor

Binds to renin blocking the cleavage of AngI to AngII

AngII unable to produce its effects

Vasodilation occurs—> BP reduced

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19
Q

Give some examples of centrally acting agents that may be used to treat hypertension, how do they lower BP?

These are rarely used in clinical practice. In which clinical situations might these be specifically used?

A

Methydopa

Clonidine

Moxonidine

Lower BP by reducing sympathetic outflow

During pregnancy

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20
Q

Give an example of. combo hypertension rx

A

Hydrochlorthiazide + amiloride

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21
Q

Briefly explain some of the pathophysiological events that occur following an MI that may lead to heart failure

A

1) Ischaemic injury (MI)
2) Scar tissue formation
3) Remodelling of tissue
4) Dilation
5) Reduced contractility
6) HF :(

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22
Q

Give some of the different methods that may be used currently to treat a patient with heart failure

A

Pharmacological methods: diuretics, ACEi, ß-blockers

Intervention: Valve surgery, transplantation, pacemaker

Lifestyle modification: Reduce salt, alcohol intake, lower BP, ++ exercise

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23
Q

Why must we initially be careful when prescribing beta-blockers in HF?

How can we overcome this?

A

Failing myocardium is dependent on the HR of the individual

Need to initiate at a LOW DOSE and titrate slowly

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24
Q

Give some examples of conditions that cause hypertension (i.e. secondary causes)

A

Conn’s syndrome

Bilateral adrenal hyperplasia

Adrenal catecholamine-secreting tumour

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25
Q

BP over what figure would be classed as a hypertensive emergency?

A

220/120 mmHg

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26
Q

Hypertensive emergency is associated with which acute conditions?

A

Pulmonary oedema

Renal failure

Aortic dissection

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27
Q

What drug could we use to treat a patient with potential fatally high BP?

Describe its mechanism of action

A

Sodium Nitroprusside

Mimics endogenous NO on vascular smooth muscle= potent vasodilator

IV

28
Q

What precautions should be taken when using Sodium Nitroprusside to treat very high BP?

A

Avoid prolonged use (>72 hours)

Caution when using in liver disease as is broken down into cyanide

29
Q

Describe the 4 physiological roles of the kidneys

(+ mnemonic to remember them)

A

Regulatory- fluid, pH, electrolyte balance

Excretory- waste, drug elimination

Endocrine- renin, erythropoetin, prostaglandins, 1alphs calcidol

Metabolism- vitamin D, polypeptides (insulin), drugs

“REEM” : |

30
Q

Where is the majority of Na+ absorbed in the kidney?

A

PCT of the nephron

31
Q

Which type of drug acts on the PCT of the nephron?

A

Carbonic anhydrase inhibitors

(1) on the diagram

32
Q

What are some of the side effects of carbonic anhydase inhibitors

A

Metabolic acidosis (due to blockage of HCO3- reabsorption)

Hypokalaemia (due to excretion of K+)

33
Q

Which part of the kidney do osmotic agents act on?

Give an example of such

A

PCT and descending limb of LoH

Mannitol

(2) on diagram

34
Q

How do osmotic agents such as mannitol help to increase water loss through their actions on the kidney?

A

Increase the osmotic gradient throughout the nephron

Retaining water in the kidney tubule rather than reabsorbing it

35
Q

What conditions might mannitol be useful in treating and which conditions might it not be as helpful?

A

Useful in brain swelling

Not as useful in oedema

36
Q

Give an example of a side effect of mannitol

A

Hypernatraemia

37
Q

Where in the kidney nephron do loop diuretics work?

How do they achieve water loss?

A

The thick ascending lumb of the loop of henle

Block Na+ and Cl- channels- stopping them from being reabsorbed and therefore stopping water reabsorption

(3) on diagram

38
Q

Besides increasing water loss, loop diuretics can be used to treat patients with high levels of _____ in their blood

A

Ca2+

39
Q

Loop diuretics can cause _____kalaemia as a side effect

A

hypo

40
Q

Where in the kidney nephron do thiazide diuretics work?

How do they increase water excretion from the kidneys?

A

Distal convoluted tubule

Block NaCl reabsorption

(4) on diagram

41
Q

Apart from NaCl channels, which other channels are blocked by thiazide diuretics?

What may be the clinical consequence of this?

A

ENaK

Hypokalaemia

42
Q

Thiazide diuretics can be helpful in the treatment of _____calcaemia

A

Hypo

43
Q

What is an unwanted side effect of thiazide diuretics?

A

Hyperuricaemia as they help to reabsorb urate

44
Q

Where in the kidney nephron do aldosterone antagonists act?

Give an example of such

A

Cortical collecting duct

(4) on diagram

Sprionolactone

45
Q

How to aldosterone antagonists increase water excretion from the kidneys?

A

Inhibit Na retention by inhibiting ENaK and NaKATPase

46
Q

Where in the kidney nephron do ADH antagonists elicit their effect?

What do these drugs do?

A

Medullary collecting duct

Effects free water absorption- loss of pure water rather than water + salt

47
Q

Give three examples of ADH antagonists

What are they each used to treat?

A

Lithium - treat mania

Deneclocycline - treat infection

Tolvaptan- Autosomal dominant Polycystic CKD (APCKD)

48
Q

How does aldosterone usually effect the kidney nephron?

A

Increases the expression of ENaC and Na/K/ATPase in the prinicple cells of the collecting duct

49
Q

How do aldosterone antagonists act as K+ sparing diuretics?

A

They inhibit the expression of ENaC and Na/K/ATPase

Don’t secrete as much K+ into tubule and therefore don’t excrete K+

50
Q

Are amiloride and triamterene alosterone antagonists?

A

NO!

They are potassium sparing, but they act by blocking ENaC channels - still K+ sparing but are weaker in their effects

51
Q

Name two substances that we may comsume in everyday life that have diuretic action

How do they work?

A

Alcohol - inhibit ADH

Caffeine - increase GFR, decrease tubular reabsorption of Na+

52
Q

Give some generic adverse drug reactions of diuretics

A

Anaphylaxis

Photosensitivity

Hypovolaemia & hypotension (activation of RAAS)

Electrolyte disturbance

53
Q

Give some specific side effects of thiazide diuretics

A

Hyperuricemia- Gout

Hyperglycaemia- DM

Erectile dysfunction

Hyperlipidaemia

Hypercalcaemia

54
Q

Give some speific ADRs of loop diuretics

A

Ototoxicity- toxic to ear!

Alkalosis

Hyperlipidaemia

Gout

55
Q

Give some examples of conditions where diuretics may be used

Give the type of diuretic used for each

A

Hypertension- Thiazide, spironolactone, loop(if kidney dysfunction)

Heart failure- Loop, spironolactone (protective to heart)

Compensated liver diease (not making albumin)- Spironolactone, loop

NephrOtic syndrome (losing albumin in urine)- Loop +/- thiazide, +/- K+ sparing

Chronic kidney disease - Loop +/- thiazide-like, AVOID K+ sparing

56
Q

How are diuretics delivered to the renal tubule?

(start in the gut, end in the tubule lumen)

A

Absorbed through the gut

Blood flows to proximal tubule

OAT transporters take across PCT basolateral membrane of epithelial cells

OAT transporters take across luminal side into the lumen of the tubule

57
Q

What is refractory oedema?

A

Peripheral oedema that does not respond to dietary sodium restriction and combined diuretic treatment including a loop diuretic

Often caused by an evident underlying cardiac or pulmonary condition

58
Q

Which diuretic type is best for the treatment of oedema?

A

Loop diuretic

59
Q

Which conditions are carbonic anhydrase inhibitors used to treat?

A

Glaucoma

Altitude sickness

60
Q

Give some examples of potentially nephrotoxic drugs

A

Aminoglycosides

Vancomycin

Aciclovir

NSAIDs

61
Q

Give some examples of drugs that are not necessarily nephrotoxic but that can make renal disease worse or cause AKI

How might each of these cause renal damage?

A

ACE inhibitors - overrides intrinsic autoregulatory mechanisms

Diuretics

Metformin- propensity to make you acidotic then + acidosis = BAD

62
Q

What do we need to take into account when prescribing in patients with CKD?

A

Avoid nephrotoxins

Gentamicin/vancomycin DOSED very carefully

Check with pharmacist whether allopurinol, digoxin, cyclosporin, LMW heparins need altering

Morphine, nitrofurantoin, statins might all cause problems

63
Q

Give some causes of hyperkalaemia

A

Movement of K+ out of cells: acidosis, hypertoncicity, muscle damage

Reduced urine loss: reduced GFR, reduced distal Na+ delivery, reduction secretion in CD

Drugs: RAAS inhibitors, NSAIDs, ENaC blockers

64
Q

What is the main concern in patients with hyperkalaemia?

A

Might lead to life-threatening cardiac arrhythmias

65
Q

What progressive ECG changes might you see on an ECG of a patient with hyperkalaemia?

A

Tall T waves

Small/absent P waves

Increased P-R interval

Wide QRS complex

“Sine wave” :(

Asystole very soon after sine wave :((((

66
Q

Give the three steps that should be taken in the management of hyperkalaemia

Give the drugs used for each step

A
  1. Protect the heart - Calcium glyconate
  2. Lower serum K+ - insulin/ dextrose (high dose salbutamol if don’t have these)
  3. Remove K+ from body - Calcium resonium
67
Q
A

Clinical Pharmacology, Therapeutics & Principles of Prescribing (22 decks)

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