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PCL 412 > Hypertension II - Drug Therapy > Flashcards

Hypertension II - Drug Therapy Flashcards

1
Q

Mention 10 classes of anti-HTN drugs.

A
  1. Diuretics
  2. Calcium channel blockers
  3. Angiotensin-converting enzyme (ACE) inhibitors
  4. Angiotensin II receptor blockers (ARBs)
  5. Beta blockers (BB)
  6. Alpha blockers
  7. Renin blockers
  8. Selective aldosterone inhibitors (Mineralocorticoid receptor antagonist)
  9. Centrally-acting alpha-2 agonists
  10. Vasodilators
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2
Q

What are the three types of diuretics?

A
  1. Thiazides
  2. Potassium-sparing diuretics
  3. Loop diuretics
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3
Q

How do thiazide diuretics work?

A

They inhibit the reabsorption of sodium and chloride in the DCT.
However, they also:
-increase potassium and bicarbonate excretion
- reduce calcium excretion and
- cause uric acid retention

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4
Q

Thiazides maybe used as monotherapy or administered adjunctively with other anti-HTN agents.
True or False?

A

True

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5
Q

Give 2 examples of thiazide diuretics.

A

Hydrochlorothiazide
Indapamide

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6
Q

How do loop diuretics work?

A

They act on the ascending loop of Henle, inhibiting the reabsorption on sodium and chloride.
They are commonly used to control volume retention.

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7
Q

What kind of diuretic is commonly prescribed for patients with decreased glomerular filtration rate or heart failure?

A

Loop diuretics

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8
Q

Loop diuretics are highly protein-bound and therefore enter the urine primarily by _______ in the proximal tubule, rather than by ______.

A

tubular secretion
glomerular filtration

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9
Q

How do potassium-sparing diuretics work?

A

They interfere with sodium reabsorption at the distal tubules, primarily in the collecting duct.
They also decrease potassium secretion, preventing loss of potassium.

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10
Q

Loop diuretics and potassium-sparing diuretics are not as effective in controlling BP as thiazide diuretics
True or False?

A

True

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11
Q

What are the general side effects of diuretics?

A

i. Hypokalaemia (except potassium-sparing diuretics)
ii. Hyponatraemia
iii. Hyperlipidaemia
iv. Hyperuricaemia - hence contraindicated in gout
v. Hyperglycemia (not safe in diabetes)
vi. Not safe in renal and hepatic insufficiency.

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12
Q

Potassium-sparing diuretics may be used in patients who can’t risk the development of hyperkalaemia, especially those taking ACE inhibitors.
True or False?

A

False.
A side effect of ACE inhibitors is hyperkalemia [high blood potassium levels]. Potassium-sparing diuretics cause the retention of potassium. Hence, they cannot be used.

Hydrochlorothiazide may be used in such cases.

ACEI should also not be administered with potassium suplements.

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13
Q

Diuretics are drugs of choice in elderly hypertensives.
True or False?

A

True.

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14
Q

Mention 2 examples of loop diuretics.

A

Torsemide
Furosemide

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15
Q

Mention 2 examples of potassium-sparing diuretics.

A

Amiloride
Spironolactone
eplerenone

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16
Q

What are the 4 types of beta blockers? Describe them

A
  1. Selective beta blockers: Block only beta-1 receptors in the heart, contractility and heart rate, thus reducing CO. They are the drug of choice in patients with existing coronary heart disease.
  2. Nonselective beta blockers: These block both beta-1 and beta-2 receptors found in the lungs. These drugs are avoided in patients with COPD.
  3. Beta blockers with alpha activity: They act on both beta receptors and alpha-1 receptors, reducing heart rate and contractility while also causing vasodilation.
  4. Beta blockers with intrinsic sympathomimetic activity: They block the action of epinephrine on the beta receptors while agonising the receptors themselves, which helps control blood pressure while still maintaining heart rate .
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17
Q

Mention 2 examples of selective beta blockers.

A

Atenolol
Bisoprolol
Propranolol

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18
Q

Mention 2 examples of beta blockers with alpha activity

A

Labetalol
Carvedilol

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19
Q

Mention 2 examples of beta blockers with intrinsic sympathomimetic activity

A

Acebutolol
Pindolol

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20
Q

What are the side effects of beta blockers?

A
  1. Bradycardia
  2. Lethargy
  3. Impotency
  4. Not safe in patients with co-existing asthma, COPD and diabetes
  5. Adverse effect on lipid profile
  6. Exacerbation of angina
  7. Myocardial infarction following abrupt discontinuation.
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21
Q

Labetalol’s actions at alpha-1 and beta-receptors result in decreased blood
pressure without a substantial decrease in resting heart rate, cardiac output, or stroke volume.
True or false?

A

True

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21
Q

Carvedilol may cause orthostatic hypotension.

True or False?

A

True.

Carvedilol, a beta blocker with alpha activity, lowers standing blood
pressure more than supine blood pressure;

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21
Q

Acebutolol, a beta blocker with ISA, is cardio-selective.

True or False?

A

True.

It affects only beta-1 receptors in the heart.

21
Q

Pindolol is indicated in the management of
hypertension and can be used alone or with other antihypertensive agents.

True or False?

A

True.

22
Q

What is the mechanism of action of calcium channel blockers? Give two examples of CCBs.

A

They block the calcium channels, preventing calcium from entering the smooth muscles of the heart. This reduces the heart’s force of contraction and keep the blood vessels dilated.
They are drugs of choice in elderly hypertensives and patients with co-existing asthma.

Should be avoided in cases with heart failure and [diabetes]
Example are:
1. Amlodipine
2. Nifedipine

22
Q

What are the side effects of of CCBs?

A
  1. Flushing
  2. Pedal edema
  3. Headache
  4. Dizziness
  5. Fatigue
22
Q

How long does it take to see an antihypertensive response with pindolol?

A

Response is seen within the first week.
Maximal response may take two or more weeks.

23
Q

Explain the mechanism of action of ACE inhibitors and give 2 examples.

A

They inhibit Angiotensin converting enzymes, thus preventing the formation of angiotensin II and blocking the major pathway of bradykinin degradation. This prevents vasoconstriction and aldosterone release.
Examples:
1. Lisinopril
2. Ramipril
3. Enalapril

24
Q

ACE inhibitors are the treatment of choice in patients with hypertension, heart failure, chronic kidney disease, and proteinuria.

True or False?

A

True.

25
Q

ACE inhibitors and ARBs are safe to use in pregnant women.

True or False?

A

False.

ACE inhibitors and ARBs cause injury or even death to developing fetuses. It should be discontinued in pregnant patients as soon as possible.

26
Q

What are the side effects of ACE inhibitors?

A
  1. Hypotension
  2. Dry cough - possibly due to bradykinin accumulation
  3. Angioedema (swelling under the skin)
27
Q

Explain the mechanism of action of Angiotensin II receptor blockers (ARBs) and give 2 examples.

A

ARBs competitively block the binding of angiotensin II to angiotensin II type I (AT1
receptors, thereby reducing effects of angiotensin II–induced vasoconstriction,
sodium retention, and aldosterone release.
Bradykinin breakdown is not inhibited.

ARBs are used for patients who are unable to tolerate ACE inhibitors. They are safer than ACE inhibitors.

Examples are:
1. Valsartan
2. Losartan

28
Q

Explain the mechanism of action of Alpha blockers and give 2 examples.

A

They block the action of catecholamines on the alpha-1 receptors, causing vasodilation.

Examples:
1. Prazosin
2. Doxazosin

29
Q

What are the drugs of choice in hypertensive patients with co-existing benign prostatic hyperplasia?

A

Alpha blockers.

30
Q

What’s a side effect of alpha blockers?

A

Postural hypotension.

31
Q

Explain the mechanism of action of centrally-acting alpha-2 agonists and give 2 examples.

A

Centrally-acting alpha-2 agonists stimulate presynaptic alpha-2 adrenergic receptors in
the brain stem, which reduces sympathetic nervous activity.

Examples:
1. Methyldopa
2. Clonidine

32
Q

What are the side effects of centrally-acting alpha-2 agonists?

A

Postural hypotension.

Clonidine has rebound effects. Methyldopa does not.

33
Q

Give an example of vasodilators.

A

Hydralazine.

Oral hydralazine is indicated for essential hypertension.

IV or IM hydralazine are indicated for severe essential hypertension emergencies.

34
Q

What is the initial dosage for oral hydralazine?

A

10 mg 4 times daily for the first 2-4 days and then 25 mg 4 times daily for 1 week.

35
Q

How do selective aldosterone antagonists work? Give 2 examples.

A

They compete with aldosterone at its receptor sites, inhibiting sodium reabsorption.

Examples:
1. Spironolactone
2. Eplerenone

36
Q

What is the initial dosage of spironolactone?

A

Initial dose ranges from 50-100 mg daily, in single or divided doses.

37
Q

What are the side effects of selective aldosterone antagonists?

A
  1. Hyperkalaemia
  2. Gynecomastia
  3. Impotence
38
Q

How do Renin inhibitors work? Give 1 example.

A

They block renin activity and inhibits conversion of angiotensinogen to angiotensin I, as a result, also decreasing angiotensin
II and thereby disrupting the renin-angiotensin-aldosterone system
feedback loop.

Example:
1. Aliskiren

Use should be avoided in pregnancy.
Renin inhibitors are still under investigation.

39
Q

What are the classifications of BP in adults?

A
  1. Normal: SBP <120 and DBP<80
  2. Prehypertension: SBP 120-139 and DBP 80-89
  3. Stage 1 hypertension: SBP 140-159 and DBP 90-99
  4. Stage 2 hypertension: SBP >=160 and DBP >= 100
40
Q

What are the initial drug choices for hypertension?

A

A. Without compelling indications:
1. Stage 1 hypertension: Thiazide-type diuretics for most. [May consider ACEI, ARB, CCB, Beta blockers or combination.]

  1. Stage 2 hypertension: 2-drug combination for most. Usually thiazide-type diuretics+ ACEI or ARB or BB or CCB.
    [That is TTD + ACEI or TTD + ARB or TTD + BB…..]

B. With compelling indications.
i. Drugs for the compelling indications and othwr antihypertensives as needed.

41
Q

What are the drugs of choice for HTN with coronary heart disease as a compelling indication?

A

ACE Inhibitors
ARBs
Calcium channel blockers
Beta blockers

42
Q

What are the drugs of choice for HTN with diabetes mellitus as a compelling indication?

A

ACE Inhibitors
ARBs

43
Q

What are the drugs of choice for HTN with heart failure as a compelling indication?

A

ACE inhibitors
ARBs
Beta blockers
Aldosterone antagonists
Diuretics

44
Q

What are the drugs of choice for HTN with previous stroke as a compelling indication?

A

ACE inhibitor + Thiazide diuretic
ARB + Thiazide diuretic
Calcium channel blockers

45
Q

What are the drugs of choice for HTN with CKD as a compelling indication?

A

ACE inhibitor + Thiazide diuretic
ARB + Thiazide diuretic
Calcium channel blockers

46
Q

The preferred drugs for HTN pregnant patients are:

A

CCBs - Nifedipine
Beta blockers - labetalol
Hydralazine
Centrally-acting alpha agonists - Methyldopa
Alpha blockers - prazosin

47
Q

Which HTN drugs should be avoided in pregnant patients?

A

ACE inhibitors
ARBs
Renin inhibitors
Aldosterone inhibitors

48
Q

CCBs are not recommended for HTN in patients with diabetes or heart failure.

True or False?

A

True.

49
Q

Can ACE inhibitors and ARBs be used together?

A

No.
This combination is potentially harmful.

50
Q

A patient presents with severe hypertension (BP >180/120), how do you handle it in the case of an emergency or urgency?

A

EMERGENCY: if there are acute, life-threatening manifestations of organ damage e.g. hypertensive encephalopathy, acute ischemic stroke, myocardial infarction, acute renal failure, pulmonary edema or aortic dissection.

  • Admit to ICU for continuous BP monitoring and IV/IM antihypertensive drug therapy.
  • Reduce SBP to <140 within first hour. In the case of aortic dissection, reduce SBP to <120

URGENCY: if there’s no compelling indication.
- Reduce SBP by no more than 25% within first hour and if stable, to 160/100 within next 2-6 hours and then cautiously reduce to normal during next 24-48 hours.

51
Q

What are the causes of resistant hypertension?

A
  1. Excess sodium intake
  2. Inadequate diuretic therapy
  3. Improper BP measurement
  4. Inadequate drug dosage
  5. Drug actions and interactions e.g. NSAIDS, illicit drugs, oral contraceptives, Sympathomimetics
  6. Excess alcohol intake
  7. Unidentifiable causes of hypertension
52
Q

Mention 5 roles of the pharmacist in hypertension management.

A
  1. Blood pressure measurement
  2. Disease state education
  3. Patient counselling
  4. Blood pressure monitoring
  5. Adherence monitoring
  6. Medication therapy management (MTM)

PCL 412 (6 decks)

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