Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Therapeutics 2 > hypertension treatment > Flashcards

hypertension treatment Flashcards

1
Q

What is essential hypertension

A

elevated arterial blood pressure with an unknown etiology

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what is secondary hypertension

A

elevated arterial blood pressure due to concurrent medical conditions or medications

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

isolated systolic hypertension definition

A

systolic BP values are elevated and diastolic BP values are not.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

resistant HTN definition

A

fail to attain goal BP while adherent to a regimen including at least 3 agents at max dose (including a diuretic) or when 4 or more agents are needed.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

orthostatic hypotension definition

A

systolic blood pressure decrease of more than 20 mmHg or a diastolic blood pressure decrease of more than 10mmHg within 3 minutes of positional change and/or increase in heart rate >20bpm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what is secondary htn caused by?

A

CKD, renovascular disease, primary aldosteronism, obstructive sleep apnea, drugs, sodium/ethanol, cushing’s syndrome, thyroid diseases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

which substances increase BP?

A

illicit drugs, caffeine, nicotine, decongestants, amphetamines, antidepressants, clozapine/olanzapine, cyclosporine, oral contraceptives, NSAIDS, steroids, oncology agents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

normotensive definition

A

no HTN in office, no HTN at home

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

sustained hypertension

A

HTN in office, HTN at home

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

masked hypertension

A

no HTN in office, HTN at home

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

white coat hypertension

A

HTN in office, no HTN at home

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

what and how often should you follow up when patient has normal blood pressure?

A
  • promote healthy lifestyle; f/u 1 year
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what and how often should you follow up when your patient has elevated BP?

A
  • initiate non-pharm treatment; f/u in 3-6 months
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what and how often should you follow up when your patient has stage 1 HTN w/ no comorbidity?

A
  • initiate non-pharm treatment; f/u in 3-6 months
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what and how often should you follow up when your patient has stage 1 HTN w/ a comorbidity?

A
  • initiate non-pharm treatment and a medication; f/u in one month
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what and how often should you follow up when your patient has stage 2 HTN

A
  • initiate 2 medications and non-pharm; f/u in one month
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

how often should htn patients at goal have a follow up?

A

every 3-6 months

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what ASCVD risk and other factor determines that patient needs a medication with stage 1 htn?

A

> 10% ASCVD risk AND/or other comorbidity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

ACC/AHA BP threshold for treatment initiation for risk >10% and/or clinical CVD

A

> 130/80 (stage 1)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

ACC/AHA BP threshold for treatment initiation for risk <10% and no clinical CVD

A

> 140/90 (stage II)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

what blood pressure is targeted with meds for secondary stroke prevention?

A

> 140/90 (stage II)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

ACC/AHA BP goal

A

<130/80

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

ACA/AHA goal for frail/elderly patient

A

<140/90

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

ADA BP goal

A

<130/80

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

KDIGO BP goal for adults with HTN and CKD

A

<120/80

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

what patient population was SPRINT trial conducted in?

A

patients without prior diabetes or stroke

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

what patient population was ACCORD trial conducted in?

A

type II diabetes and CVD risk

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

non-pharm treatment options

A

weight loss, DASH diet, decrease sodium intake, increase potassium intake, physical activity, decrease alcohol intake

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is first line for htn?

A

thiazide-like diuretics, ACEi/ARBs, and CCBs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

takeaways of ALLHAT trial?

A
  • thiazide diuretics should be first line, followed by calcium channel blockers, ACE inhibitors (and ARBs)
  • most patients with HTN need more than one drug
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What is first line antihypertensive agent for stable ischemic heart disease?

A

Beta-blockers or ACEi/ARBs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What are second and last line options for hypertension with stable ischemic heart disease

A

dihydropyridine CCBs, then thiazide diuretics, then aldosterone antagonists

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

heart failure with reduced ejection fraction guidelines for hypertension

A

follow heart failure guidelines; AVOID non-dihydropyridine CCBs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

what drugs can be used for hypertension with heart failure and preserved ejection fraction, and what are their indications?

A
  • diuretics: fluid overload
  • ACEi/ARBs: elevated BP
  • B-blockers: elevated HR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

what antihypertensive agent is preferred after a kidney transplant?

A

CCBs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Which medications are preferred in CKD stage 1 or 2 WITHOUT albuminuria?

A

Any first line options

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

which medications are preferred in cerebrovascular disease for secondary stroke prevention?

A
  • ACE/ARBs
  • thiazide diuretics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

When should ACE/ARBS and thiazide diuretics be initiated for secondary prevention of stroke?

A

On when BP>140/90

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

which antihypertensives are preferred in patients with diabetes?

A

any first line agent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

When are ACE/ARBS preferred in patients with diabetes

A

in presence of albuminuria >300mg/day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Preferred agents in pregnancy

A
  • methyldopa
  • nifedipine
  • labetalol
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

contraindicated agents in pregnancy

A
  • ACE/ARBs
  • direct renin inhibitors (aliskiren)
  • thiazide diuretics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Stable ischemic heart
disease treatment

A

ACE-I/ARB and BB first, then CCB can be added if still not controlled

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

HFrEF treatment for HTN

A

ACE-I/ARB/ARNI, mineralocorticoid receptor antagonists, diuretics and BB first line

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

HFpEF treatment for HTN

A

Diuretics first line (if symptomatic); if persistent HTN, ACE-I/ARB or BB (if HR elevated)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

CKD treatment

A

If albuminuria, ACE-I (ARB if intolerant) first line

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Renal transplant HTN treatment

A

CCB (reduces graft loss and maintains higher GFR) first line over ACE-I (anemia,
hyperkalemia and lower GFR may result)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Secondary stroke
prevention HTN treatment

A

Thiazide, ACE-I or ARB or thiazide + ACE-I
*only need to start if BP >140/90

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Diabetes HTN treatment

A

Any first line option but ACE-I/ARB if albuminuria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

AF HTN Treatment

A

ARB may be useful for prevention of recurrence of AF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Aortic disease HTN treatment

A

BB (help improve survival)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Black patients with HTN treatment

A

Thiazide or CCB unless HF or CKD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

pregnancy HTN treatment

A

Methyldopa, nifedipine or labetolol

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

what are the thiazide diuretics used for HTN

A

hydrochlorothiazide, chlorthalidone, indapamide, metolazone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

what are the loop diuretics used for HTN?

A

furosemide, torsemide, bumetanide

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

what are the aldosterone antagonists used for HTN?

A

spironolactone, eplerenone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

what are the potassium sparing diuretics used for HTN?

A

triamterene, amiloride

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

what is the most potent thiazide like diuretic?

A

chlorthalidone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

what is the frequency for all thiazide diuretics?

A

1qd

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

dosing for hctz?

A

12.5 to 25mg daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

dosing for chlorthalidone?

A

12.5 to 25mg daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

what is the frequency for all loop diuretics?

A

1-2 times per day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

which loop diuretic can be used with a sulfa allergy?

A

ethacrynic acid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

furosemide dosing

A

20mg to 80mg QD to BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

torsemide dosing

A

2.5mg to 10mg QD to BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

bumetanide dosing

A

0.5mg to 2mg QD to BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

frequency for aldosterone antagonists

A

qd or bID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

dosing for spironolactone

A

12.5 to 100mg qd to bid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

amiloride dosing

A

5 to 10mg qd to BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

dosing for eplerenone

A

50 to 100mg qd to BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

frequency for potassium sparing diuretics

A

qd to bID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

ACEi with frequency 1qd

A

fosinopril, lisinopril, perindopril, trandolapril

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

triamterene dosing

A

50 to 100mg qd to BID

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q

ACEi with frequency of BID to TID

A

Captopril

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

normal frequency for ARBs

A

1qd

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

ARBs that can be used qd or BID

A

eprosartan or losartan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

aliskiren dosing

A

150 to 300mg once daily

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

what is the frequency for most dihydropyridine CCBs?

A

1qd

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

which dihydropyridine CCBS are dosed BID

A
  • isradipine and nicardepine SR
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

nondihydropyridine drugs

A

diltiazem ER and verapimil ER

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q

diltiaem and verapamil frequency

A

1qd or BID

78
Q

Patient populations with additional benefit from dihydropyridine CCBs

A

raynauds syndrome, elderly patients with isolated systolic HTN

79
Q

Patient populations with additional benefit from nondihydropyridine CCBs

A

Afib
patients with angina who cannot tolerate a beta blocker

80
Q

contraindications for nondihydropyridine CCBs

A

heart block, left ventricular dysfunction

81
Q

what CCB should be chosen in patients with heart failure

A

amlodipine

82
Q

what drug interaction occurs with all CCBS

A

CYP 3a4 inhibitors/inducers/grapefruit juice

83
Q

indications for b blocker in HTN

A

heart failure and CAD

84
Q

populations with benefit for b-blockers in HTN

A

tachyarrhythmia, tremor, migraine, thyrotoxicosis

85
Q

which cardioselective beta blocker also caused nitric oxide induced vasodilation?

A

nebivolol

86
Q

which forms of metoprolol are long and short acting?

A

succinate- long acting
tartrate- short acting

87
Q

what kind of beta blocker is metoprolol

A

beta-1 selective (cardioselective)

88
Q

how are the b-1 blockers dosed?

A

1qd

89
Q

how is metoprolol tartrate dosed?

A

BID

90
Q

what are the non-selective beta blockers

A

propanolol and nadolol

91
Q

how are nadolol and propanolol LA dosed?

A

1qd

92
Q

how is propanolol IR dosed?

A

BID

93
Q

when should non-selective beta blockers be avoided?

A

bronchospastic airway disease

94
Q

what beta blockers have intrinsic sympathomimetic activity?

A

acebutolol, penbutolol, pindolol

95
Q

which ISA beta blockers are dosed BID

A

acebutolol and pindolol

96
Q

which ISA beta blockers are dosed QD?

A

penbutolol

97
Q

which b blockers have mixed alpha and beta activity?

A

carvedilol and labetalol

98
Q

what are the direct arterial vasodilators?

A

minoxidil and hydralazine

99
Q

what should the direct arterial vasodilators be used with?

A

beta blocker and diuretic

100
Q

when would you use a direct arterial vasodilator?

A

last line; with resistant HTN or sevre CKD/hemodialysis

101
Q

what is the frequency for hydralazine?

A

bid to qid

102
Q

what is the frequency for minoxidil?

A

1qd to tid

103
Q

side effects of both direct arterial vasodilators

A

palpitations, tachycardia, chest pain, GI effects, headache, hematologic dyscrasia, hepatotoxicity, and fluid retention

104
Q

side effect specific to hydralazine

A

lupus-like syndrome and rash

105
Q

side effect specific to minoxidil

A

hair growth on face, arms, back, and chest

106
Q

what is the minoxidil boxed warning for?

A
  • may cause pericarditis and pericardial effusion, may increase oxygen demand and exacerbate angina
107
Q

what are the alpha-1 blockers

A

terazosin, doxazosin, prazosin

108
Q

when are the alpha-1 blockers used

A

in patients with BPH

109
Q

what is an AE of alpha-1 blockers

A

orthostatic hypotension

110
Q

what are the central alpha-2 agonists

A

clonidine, methyldopa, and guanfacine

111
Q

what is the dosing frequency for clonidine

A

BID to TID max 2.4mg/day

112
Q

what is the dosing frequency for methyldopa

A

250-500mg BID

113
Q

what is the dosing frequency for guanfacine

A

0.5-2mg once daily

114
Q

what are the AE of alpha-2 agonists

A

CNS depression, dizziness, fatigue, anticholinergic effects, bradycardia, reflex tachycardia, and fluid retention

115
Q

what are the monitoring parameters for ACE/ARBs

A

BUN/Scr and potassium

116
Q

what are the monitoring parameters for CCBs

A

heart rate (non-dihydropyridine only)

117
Q

what are the monitoring parameters for aldosterone antagonists

A

BUN/Scr, potassium

118
Q

what are the monitoring parameters for other diuretics

A

BUN/SCr, electrolytes (K,Mg, Na), and uric acid (thiazides only)

119
Q

what are the monitoring parameters for beta blockers?

A

heart rate

120
Q

risk factors for resistant HTN

A

older age, obesity, CKD, diabetes, and african american

121
Q

what must you rule out to diagnose resistant HTN?

A

secondary causes, nonadherence, and white coat HTN

122
Q

what agent/class was determined to be the most effective add-on to the maximized 3-drug regimen in adults with resistant hypertension

A

spironolactone

123
Q

what clinical trial determined spironolactone the best add-on to resistant HTN

A

PATHWAY-2

124
Q

hypertensive urgency

A

BP >180/120 with no evidence of end organ damage

125
Q

hypertensive emergency

A

BP> 180/120 with evidence of organ damage

126
Q

what are symptoms of hypertensive emergency

A

headache, chest pain, SOB, back pain, numbness/weakness, change in vision, difficulty speaking

127
Q

causes of hypertensive crisis

A
  • chronic hypertension
  • medication non-adherence
  • medication/substance use
  • pregnancy
  • renal disease
  • endocrine disorders
128
Q

what are the steps for hypertensive emergency treatment?

A

hour 1: reduce BP by no more than 25%
hours 2-6: reduce BP <160/100-110
hours 6-48: reduce BP to goal

129
Q

pharmacotherapy treatment general statements

A

IV therapy preferred
therapy with fast onset/offset and titratable preferred

130
Q

what are the DHP calcium channel blockers used for hypertensive emergency?

A

nicardepine, clevidipine

131
Q

nicardepine info

A
  • titratable IV infusion
  • short onset and duration
    pro: low risk for AE
    cons: contraindicated in severe aortic stenosis, reflex tachycardia
132
Q

clevidipine info

A
  • titratable IV infusion
  • short onset and duration
  • pro: lack of accumulation in organ impairment
  • cons: contraindicated in severer aortic stenosis, contraindicated with soy/egg allergy, elevates triglycerides, need to change IV lines every 12 hours, overall more SE, may induce Afib
133
Q

what are the vasodilators used for hypertensive crisis

A

nitroglycerin, nitroprusside, and hydralazine

134
Q

nitroglycerin info

A
  • titratable IV infusion
  • short onset and duration of action
  • pro: beneficial in coronary ischemia
  • Cons: tolerance with prolonged use, interact with PDE-5 inhibitors, dose-limited headache and reflex tachycardia.
  • Use caution with high ICP, excessive hypotension in hypovolemia
135
Q

sodium nitroprusside info

A
  • titratable iv infusion
  • very short onset and duration
  • cons: tolerance with prolonged use, interact with PDE-5 inhibitors, dose-limiting headache and reflex tachycardia, caution with high ICP, may cause excessive hypotension.
  • cyanide toxicity; do not use with renal/hepatic dysfunction
136
Q

hydralazine info

A
  • IV push
  • pros: may be used in patients with bradycardia
  • cons: not titratable, less predictable PK, and rebound tachycardia.
137
Q

beta blockers used in hypertensive crisis

A

labetalol and esmolol

138
Q

labetalol info

A
  • IV push and titratable IV infusion
  • short onset and long duration
  • pros :decreases HR and BP
  • cons: decreases HR, contraindicated with severe bradycardia, HF, and reactive airway disease
139
Q

esmolol info

A
  • titratable IV infusion
  • very short duration and onset
  • pro: decreases HR, cardioselective (can be used in patients with reactive airway disease)
  • cons: NOT MONOTHERAPY, avoid in bradycardia and ADHF
140
Q

ace inhibitors used for hypertensive crisis

A

enalaprilat

141
Q

enalaprilat info

A
  • IV push
  • short onset, long duration
  • may be beneficial in emergencies related to renin excess
  • cons: delayed onset and peak
  • contraindications: pregnancy, AKI, hyperkalemia, acute MI, bilateral renal artery stenosis
142
Q

alpha2 agonist used in hypertensive crisis

A
  • clonidine
143
Q

clonidine info

A
  • oral medication (hypertensive urgency not emergency)
  • delayed onset and peak
  • pros: can be used when no IV access
  • cons: often used inappropriately in emergency settings, can cause hypertensive crisis on withdrawal
144
Q

what are the conditions with specific blood pressure goals

A

stroke, aortic dissection, severe eclampsia/preeclampsia, and pheochromocytoma crisis

145
Q

what medications are used in crisis for acute decompensated HF with pulmonary edema?

A

1st line: sodium nitroprusside, nitroglycerin
2nd line: nicardipine, clevidipine
AVOID: beta blockers and non DHP CCBs

146
Q

what medications are used in HTN crisis for aortic dissection

A

1st line: beta blocker (labetalol, esmolol), then vasodilator (CCB or other vasodilator) (sodium nitroprusside, nicardipine, clevidipine

147
Q

what medications are used in crisis for acute coronary syndrome

A

1st line: beta blockers (esmolol, labetalol), vasodilators (nitroglycerin, nitroprusside, and nicardipine)
caution with: non DHP CCBs
avoid: beta blockers

148
Q

what medications are used in crisis for AKI

A

Most IV antihypertensives
caution: sodium nitroprusside
avoid: enalaprilat

149
Q

what medications are used in crisis for eclampsia/ severe preeclampsia?

A

1st line: hydralazine, labetalol, or nicardipine
AVOID: enalaprilat, nitroprusside

150
Q

what medications are used in crisis for stroke

A
  • 1st line: nicardipine, clevidipine, labetalol
  • avoid: nitrates
151
Q

definition of pulmonary hypertension

A

mean pulmonary arterial pressure > 20 mmHg at rest
- common

152
Q

definition of pulmonary arterial hypertension

A

progressive disease involving endothelial dysfunction = elevated pulmonary arterial pressure and pulmonary vascular resistance
- rare

153
Q

what are the causes for pulmonary arterial hypertension?

A
  • unknown
  • genetic
  • drug and toxin exposure
  • CHD, HIV, connective tissue disorders
154
Q

treatment for PAH

A

PAH specific medications, CCB, and lung transplantation

155
Q

difference between PH, and PAH

A

PAH has a pulmonary artery wedge pressure of <15mmHg and pulmonary vascular resistance of >2 wood units

156
Q

signs and symptoms of PAH

A

fatigue, fainting or lightheadedness, chest pain, SOB, palpitations, edema

157
Q

What tests should be done to diagnose PAH

A

echocardiogram (evaluates potential causes, right ventricular function, estimates pulmonary arterial pressure, and pulmonary vascular resistance), right heart catheterization (confirms diagnosis and estimates severity), exercise testing (distance walked in 6 minutes), biomarkers (BNP and NTproBNP)

158
Q

disease progression and vascular injury (what are the signs of endothelial dysfunction)

A

decreased nitric oxide synthase
decreased prostacyclin production
increased thromboxane production
increased endothelin 1 production

159
Q

What are the WHO functional classes?

A

Class 1: symptom free when physically active or resting
Class 2: slight limitation of physical activity; comfortable at rest
Class 3: marked limitation in physical activity; less than ordinary activity causes symptoms; comfortable at rest
Class 4: significant symptoms with activity; symptoms at rest

160
Q

what is the 1st step for pharmacotherapy after/during diagnosis for PAH

A

Acute vasoreactivity testing; positive response? Initiate CCB

161
Q

which agents are used for an acute vasoreactivity test?

A

inhaled nitric oxide (direct pulmonary vasodilator) and IV epoprostenol (prostacyclin)

162
Q

what indicates a positive vasoreactivity test?

A

drop in mPAP >10mmHg with PAP <40mmHg and improved cardiac output

163
Q

What are the drug classes mainly used for PAH?

A

1st line: CCB (if determined by vasoreactivity test)
direct pulmonary vasodilator (used in vasoreactivity test)
PDE-5 inhibitors: sildenafil, tadalafil
Endothelin Receptor antagonists (ERAs): bosentan, ambrisentan, macitentan
Prostacyclins: epoprostenol, iloprost, treprostinil, selexipag
Soluble guanylyl cyclase stimulator: riociguat

164
Q

which calcium channel blockers are used in PAH? and are they DHP or no?

A

diltiazem - non DHP
amlodipine - DHP
nifedipine - DHP
- no verapamil used due to negative ionotropic effects

165
Q

what to do after adding CCB to WHO FC I or II?

A

Check for improvement; if none, start additional or alternative PAH therapy

166
Q

What if the functional class II treatment?

A

Combo therapy with ambrisentan (ERA) and tadalafil (PDE-5) or monotherapy with ERA, riociguat, or PDE-5

167
Q

What is the functional class 3 treatment without rapid progression?

A

Combo therapy or monotherapy (same as above)

168
Q

which drug classes work in the nitric oxide pathways?

A
  • PDE-5 inhibitors
  • soluble guanylate cyclase inhibitor
169
Q

Which drugs work in the endothelin pathway?

A

ERAs

170
Q

Which drugs work in the prostacyclin pathway

A

prostacyclins: epoprostenol, iloprost, and treprostinil
IP prostacyclin receptor antagonist: selexipag

171
Q

PDE-5i MOA

A

decrease conversion of cGMP to GMP
increased cGMP = pulmonary vasodilation

172
Q

PDE-5 indications in PAH

A
  • monotherapy or combo
  • first line in FC II and III
173
Q

PDE-5 metabolism

A

CYP 3a4 substrates

174
Q

Warnings and AEs for PDE-5 i

A
  • avoid with nitrates (hypotension)
  • no black box warnings
  • ADRs: hearing loss, sudden vision loss, hypotension
175
Q

Frequency for PDE-5i

A

sildenafil - TID
tadalafil - daily

176
Q

ERA MOA

A

endothelin receptor antagonist - blocking endothelin = vasodilation

177
Q

when are ERAs indicated in PAH?

A

used in FC 2-4
can be used in combo with tadalafil
ex) tadalafil & ambrisentan (first line class 2 and 3)

178
Q

ETA and ETb receptor location and function

A

ETA receptors- located on pulmonary smooth muscle walls; promote vasoconstriction, proliferation, and inflammation
ETb receptors- located on endothelium; promote vasodilation; stimulate NO and prostacyclin
ETb receptors- located on muscle cells; cause vasoconstriction and cell proliferation

179
Q

bosentan dosing, specific SE, metabolism, and selectivity

A
  • dosed BID
  • cause abnormal LFTs (liver injury)
  • CYP 2C9 and 3A4 substrate (biliary excretion)
  • Mixed ETa and ETb selectivity
180
Q

ambrisentan dosing, specific SE, metabolism, and selectivity

A
  • dosed daily (oral)
  • causes edema, may cause liver injury
  • CYP 3A4 substrate; biliary>urinary excretion
  • ETa selective
181
Q

macitentan dosing, specific SE, metabolism, and selectivity

A
  • dosed daily
  • may cause kidney injury
  • cyp 3A4 substrate, urinary»biliary excretion
  • mixed ETa and ETb selectivity
182
Q

AE of all ERAs

A
  • all cause some peripheral edema (mostly ambrisentan)
  • all cause LFT abnormalities (mostly bosentan (hepatotoxicity))
  • all cause anemia and decrease hemoglobin
  • all cause embryo/fetal toxicity (REMS program)
  • do not initiate if LFT >3x ULN
183
Q

monitoring for ERAs

A

pregnancy tests monthly, LFTs (not for ambrisentan), and hemoglobin

184
Q

what is the soluble guanylate cyclase inhibitor

A

riociguat (Adempas)

185
Q

What drug can riociguat NOT be used with

A

PDE-5 inhibitors

186
Q

what was the result of the AMBITION trial

A

combo therapy (tadalafil and ambrisentan) better than monotherapy (tadalafil or ambrisentan)
- combo therapy also causes more AE than monotherapy

187
Q

TRITON trial results

A

triple therapy (macitentan, tadalafil, and selexipag) no better than combo therapy (tadalafil and macitentan) unless disease was rapidly progressing

188
Q

Functional class III treatment with rapid progression

A

parenteral prostanoids (subq or IV treprostinil or IV epoprostanol)
or no parenteral prostenoids (inhaled/oral prostenoid + ERA or PDE-5i)

189
Q

Functional class IV treatment

A

parenteral prostenoids (SC treprostanil or IV treprostenil or IV epoprostenol)
no parenteral prostenoids (inhaled/oral prostenoid + ERA or PDE-5i)

190
Q

prostacyclins MOA

A
  • stimulate cAMP pathway; increase pulmonary vasodilation
191
Q

prostacyclins indication PAH

A
  • reserved for class III and IV patients
  • parenteral first line
  • may be used in combination with ERA, PDE-5i, or riociguat
192
Q

prostacyclins AE

A

hypotension, thrombocytopenia

193
Q

what are the oral prostacyclins

A

treprostinil and selexipag

194
Q

what are the inhaled prostacyclins

A

iloprost and treprostinil

195
Q

what is the subQ prostacyclin

A

treprostinil

196
Q

what are the IV prostacyclins

A

treprostinil and epoprostenol (must be given continuous IV)

Therapeutics 2 (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions