Hypertensives Flashcards
Angiotensin II causes _________ and __________ leading to retention of _________
vasoconstriction
&
increased release of aldosterone
Na+ and H2O
RAAS inhibitors decrease blood pressure by _________
inhibiting the effects of Angiotensin II
What classes of drugs have shown to slow the progression of kidney disease in patients with albuminuria?
ACE inhibitors and ARBs
Angiotensin II constricts the ____________ of the nephron, causing increased workload in the glomeruli; which over time, results in _________
efferent arterioles
kidney damage
In heart failure, ACE inhibitors and ARBs protect the myocardium from what?
remodeling effects of Angiotensin II
RAAS inhibitors should NOT be used in combination due to increased risk of _________
adverse effects
RAAS inhibitors include _____
ACE inhibitors, ARBs, aliskiren, ARNI
What is a potentially fatal adverse effect that can occur with the use of any RAAS inhibitor? Who is at higher risk?
Angioedema: the swelling of the deeper layers of the skin caused by a build up of fluid.
More common with ACE inhibitors than ARBs or aliskiren
black patients
If a patient develops angioedema with any RAAS inhibitor then __________
all other RAAS inhibitors SHOULD BE AVOIDED
What class of drugs blocks the conversion of Angiotensin I to Angiotensin II? and what is the result?
ACE Inhibitors
decrease in vasoconstriction and decrease in aldosterone secretion
they also block the degradation of bradykinin, which is thought to contribute to vasodilatory effects and side effects of dry /hacking cough & angioedema.
What class of drugs blocks the degradation of bradykinin?
ACE inhibitors,
this is thought to contribute to the vasodilatory effects & side effects of a dry/hacking cough and angioedema
Lotensin *
benazepril
Vasotec *
enalapril
Vasotec IV *
enalaprilat
Prinivil *
lisinopril
Zestril *
lisinopril
Qbrelis
lisinopril oral solution
Accupril *
quinapril
Altace *
ramipril
Uncontrolled Hypertension places the patient at greater risk for ________
heart disease, stroke and kidney disease
Most patients have ________ hypertension. The cause is unknown.
primary or essential hypertension
secondary hypertension can be caused by _____________
renal disease (chronic kidney disease), adrenal disease, obstructive sleep apnea, or drugs
___________ is responsible for the conversion of angiotensinogen to angiotensin I
Renin
________ directly inhibits renin preventing the conversion of angiotensinogen to angiotensin I
Renin Inhibitor
Angiotensinogen is released by the _______
liver
Renin is released by the ______
kidneys
BP assessments should be based on an average of at least ____________readings on _________, preferably standardized to the timing of medication administration
2 readings
2 separate occasions
The ACC/AHA has defined 4 categories of blood pressure in adults:
normal blood pressure: SBP < 120mmHg AND DBP < 80mmHg
elevated BP: SBP 120-129mmHg AND DBP < 80mmHg
Stage 1 HTN: SBP 130-139mmHg oorrr DBP 80-89
Stage 2 HTN: SBP >= 140mmHg oorrr DBP >= 90mmHg
normal blood pressure =
SBP < 120mmHg AND DBP < 80mmHg
elevated blood pressure =
SBP 120-129mmHg AND DBP < 80mmHg
Stage 1 HTN =
SBP 130-139mmHg ooorrrrr DBP 80-89mmHg
Stage 2 HTN =
SBP >= 140mmHg ooorrrr DBP >= 90mmHg
Lifestyle interventions are essential to prevent hypertension. Proven interventions include:
Weight loss (1kg of weight loss decreases BP by ~1 mmHg)
heart healthy diet [DASH eating plan (Dietary Approaches to Stop Hypertension] that is high in fruits, vegetables, fiber and low fat dairy products
Reduce sodium intake to < 1500mg daily
Routine physical activity
Limiting alcohol consumption to one drink daily for women and two drinks daily for men
Tobacco cessation
controlling blood glucose and cholesterol to reduce cardiovascular disease risk
What is the correct way to use Blood pressure monitor?
first go to restroom and empty bladder
Sit in a chair (both feet on the floor) and relax for at least 5 minutes
Use the correct cuff size
Support the arm at heart level (resting on a desk)
Wait 1-2 minutes in between measurements
What Not to do when using a blood pressure monitor?
DON’T
talk
sit or lie down on the examination table
drink caffeine, exercise or smoke for 30 minutes prior
Use a finger or wrist monitor (less accurate)
Key Drugs that can increase Blood Pressure
Amphetamines
Cocaine
Decongestants (pseudoephedrine, phenylephrine)
Erythropoiesis-stimulating agents
Immunosuppressants (cyclosporine)
NSAIDs
Systemic steroids
What are some natural products that can reduce blood pressure?
Although not recommended by guidelines: Fish oil, coenzyme Q10, L-arginine, and garlic have some evidence for reducing blood pressure and overall cardiovascular risk.
What are the four preferred drug classes for Tx hypertension?
Ace inhibitors
ARBs
thiazides
(DHP) dihydropyridine calcium channel blockers
When do we start Treatment for Hypertension in patients?
If patients have:
Stage 2 Hypertension
or
Stage 1 Hypertension AND 1 of the following:
1) clinical CVD (stroke, heart failure, or coronary heart
disease)
2) 10 year ASCVD risk >= 10%
3) Does not meet Blood pressure goals after 6 months of
lifestyle modifications
What is Blood Pressure Goal?
All patients < 130/80 mmHg
Initial drug selection for hypertension in patients that are:
Non-black
thiazides, DHP CCBs, ACE inhibitors, or ARBs
Initial drug selection for hypertension in patients that are:
Black
thiazide or DHP CCBs
Initial drug selection for hypertension in patients that have CKD*** (all races):
ACE inhibitor or ARB (to slow the progression to ESRD)
***CKD: stage 3 (eGFR < 60mL/min/m^2) and/or albuminuria (urine albumin >= 300mg/day or albumin: creatinine ratio >= 300mg/g)
Initial drug selection for hypertension in patients that have Diabetes with albuminuria (all races):
ACE inhibitor or ARB
Initial drug selection for hypertension in patients that have Diabetes with CAD*** (all races):
Ace inhibitor or ARB
When do we start 2 first-line drugs (from preferred drug classes) in Stage 2 hypertension?
If SBP and DBP are > 20/10 mmHg above goal
ex. 150/90mmHg
The ADA recommends a goal BP of ___________ for patients with diabetes and high ASCVD risk, and __________ for patients at lower risk
< 130/80 mmHg
< 140/90 mmHg
The 2021 KDIGO guidelines recommend a goal SBP __________ for patients with hypertension and CKD
< 120 mmHg
which hypertension drugs have Boxed warnings for Fetal toxicity in pregnancy and should be stopped immediately?
ACE inhibitors
ARBs
aliskiren
Antihypertensive drugs can be used in pregnancy to Tx?
preeclampsia
gestational hypertension ( hypertension that develops during pregnancy)
chronic hypertension ( hypertension before pregnancy)
Preeclampsia occurs after ___________of the pregnancy and is evident by elevated blood pressure and proteinuria in the majority of cases
week 20
Preeclampsia
a serious blood pressure condition that develops during pregnancy, having high blood pressure and high levels of protein in their urine
Pregnant patients with chronic hypertension (hypertension before pregnancy) should receive treatment if ________
SBP >= 160mmHg or DBP >= 105mmHg
In patients at high risk of preeclampsia, a __________ is recommended after the first trimester
daily low aspirin
The American College of Obstetricians and Gynecologists recommend ________ and _________ as first line treatments. _________ is also recommended but may be less effective at lowering BP.
labetalol (Trandate, Normodyne)
nifedipine extended release (Procardia XL, )
methyldopa (Aldomet)
Pregnant patients with chronic hypertension should have a blood pressure maintained between __________
120-160 mmHg SBP AND 80-110 mmHg DBP
Zestoretic *
Lisinopril/hydrochlorothiazide
Lotrel *
benazepril/amlodipine
Maxzide *
Triamterene/HCTZ
Hyzaar *
losartan/HCTZ
Exforge *
valsartan/amlodipine
Dyazide *
triamterene/HCTZ
Benicar HCT *
olmesartan/HCTZ
Diovan HCT *
valsartan/HCTZ
Tenoretic *
atenolol/chlorthalidone
Ziac *
bisoprolol/HCTZ
Edarbyclor
azilsartan/chlorthalidone
Lotensin HCT
benazepril/HCTZ
Vaseretic
enalapril/HCTZ
Avalide
irbesartan/HCTZ
Micardis HCT
telmisartan/HCTZ
Tribenzor
olmesartan/amlodipine/hydrochlorothiazide
Azor
olmesartan/amlodipine
Twynsta
telmisartan/amlodipine
Tekturna HCT
aliskiren/HCTZ
Lopressor HCT
metoprolol tartrate/HCTZ
Dutoprol
metoprolol succinate/HCTZ
Exforge HCT
valsartan/amlodipine/HCTZ
Aldactazide
spironolactone/HCTZ
Thiazide-type diuretics inhibit __________ reabsorption in the __________. This causes increased excretion of ____________
Na+
distal convoluted tubules of the nephrons
Na+ , Cl- , H2O , K ( sodium, chloride, water, potassium)
Microzide *
hydrochlorothiazide
Diuril
chlorothiazide
Mykrox
metolazone (thiazide type diuretic)
Lozol
indapamide (thiazide type diuretic)
Thiazide-Type Drug interactions
Drugs that can cause sodium and water retention can decrease the effectiveness of antihypertensives. (Do not use in combination)
ex. NSAIDs
Thiazide diuretics and lithium DDI
thiazide diuretics can decrease lithium renal clearance and increase the risk of lithium toxicity. Do not use in combination if possible.
Thiazide diuretics and dofetilide DDI
thiazide diuretics can increase dofetilide serum concentrations leading to an increase risk of QT prolongation; do not use in combination
Thalitone *
chlorthalidone (thiazide type diuretic)
what are the contraindications for thiazide type diuretics?
Hypersensitivity to Sulfonamide-derived drugs (not likely to cross react), anuria (failure of the kidneys to produce urine)
There is increased excretion of electrolytes _______ with the use of thiazide type diuretics
Na, Mg, K,
Thiazide diuretics are not effective when ___________, except for ______
CrCl < 30ml/min, metolazone
Which thiazide type diuretic is the only one available in a IV formulation?
chlorothiazide
thiazide type diuretics, should be taken early in the morning to avoid ________
nocturia (get up at night to use bathroom)
DHP CCBs (dihydropyridine calcium channel blockers) are used for: __________
hypertension, chronic stable angina, and Prinzmetal’s angina
Prinzmetal’s angina:
a known clinical condition characterized by chest discomfort or pain at rest with transient electrocardiograph changes in the ST segment, and with a prompt response to nitrates
MOA of DHP CCBs -
they inhibit Ca++ ions from entering vascular smooth muscle and myocardial cells, this causes peripheral arterial vasodilation “which decreases SVR and BP” (systemic vascular resistance and blood pressure) and coronary artery vasodilation
Norvasc *
amlodipine
Katerzia
amlodipine oral suspension
Cardene IV *
nicardipine IV
Adalat CC *
nifedipine ER
Procardia XL *
nifedipine ER
Procardia
nifedipine IR
Sular
nisoldipine ER
Plendil
felodipine ER
Cleviprex
clevidipine
What is the Contraindication with the drug Nicardipine
Should NOT be used in advanced aortic stenosis
___________ is considered the safest if a CCB must be used to lower BP in heart failure with reduced ejection fraction
amlodipine
__________ is a drug of choice in pregnancy
Nifedipine ER
DHP CCBs (eg. nifedipine ER) are used to prevent peripheral vasoconstriction in __________
Raynaud’s (cold/blue fingers)
Do NOT Use Nifedipine IR for _____________
chronic hypertension (hypertension before pregnancy) or acute blood pressure reduction in non-pregnant adults (profound hypotension, MI and/or death has occurred)
Side effects with DHP CCBs
generally well tolerated, peripheral edema/headache/flushing/palpitations/reflex tachycardia/fatigue (worse with nifedipine IR) nausea, gingival hyperplasia (more with non-DHP CCBs)
Which DHP CCBs have an OROS/gel matrix formulation and can leave a ghost tablet (empty shell) in stool
Adalat CC and Procardia XL: Nifedipine ER formulations
If patient has an allergy to soybeans, soy products or eggs, which CCB is contraindicated for the patient??
Cleviprex (clevidipine) - DHP CCB
Which DHP CCB comes as a lipid emulsion (providing 2 kcal/mL) and is a milky white in color?
Cleviprex (clevidipine)
What is the maximum time of use after vial puncture of Cleviprex?
12 hours
Propofol (_________) is another lipid emulsion that provides _________ kcal/mL and requires tubing and vial changes every 12 hours
Diprivan
1.1kcal/mL
The non-DHP CCBs include ________ and ________
verapamil and diltiazem
Primarily the non-DHP CCBs are used to ____________. Sometimes are used for ______
control HR in certain arrhythmias (atrial fibrillation)
hypertension and angina
MOA for non-DHP CCBs:
they inhibit Ca++ ions from entering vascular smooth muscle and myocardial cells, by blocking Ca++ channels, BUT are more selective for the myocardium than the DHP CCBs.
The decrease in blood pressure produced by non-DHP CCBs is due too ____________
negative inotropic (decrease force of ventricular contraction)
&
negative chronotropic (decrease heart rate) effects
Cardizem *
diltiazem
Tiazac *
diltiazem
Calan SR *
verapamil
Verelan
verapamil
what are the contraindications with diltiazem
1) patient has Sick Sinus Syndrome or a 2nd or 3rd degree AV block —- Unless they have a functioning ventricular pacemaker
2) patient has severe hypotension ( less than 90 mmHg systolic) or cardiogenic shock
3) hypersensitivity to the drug
4) patient with acute myocardial infarction and pulmonary congestion
what are the contraindications with verapamil
1) atrial flutter or atrial fibrillation and an accessory by pass tract
2) severe left ventricular dysfunction
3) severe hypotension ( less than 90 mmHg systolic) or cardiogenic shock
4) patient has Sick Sinus Syndrome or a 2nd or 3rd degree AV block —- Unless they have a functioning ventricular pacemaker
Non-DHP CCBs are used to _________
reduce rapid heart rate in atrial fibrillation
IV:PO conversions of non DHP CCBs ____
are NOT 1:1
side effects with non-DHP CCBs include _________
edema, constipation (more with verapamil) gingival hyperplasia
headache, dizziness
Warnings with using non-DHP CCBs include _________
Heart failure (may worsen symptoms), bradycardia, hypotension. increased LFTs
cardiac conduction abnormalities (diltiazem)
hypertrophic cardiomyopathy (verapamil)
All CCBs are major substrates of __________ except for _________. Do NOT use with ________
CYP450 3A4
clevidipine
grapefruit juice
diltiazem and verapamil are inhibitors of _________
P-gp and moderate inhibitors or CYP3A4
Patients who take statins should use lower doses of ________ and __________ or can use a statin that is NOT metabolized by CYP3A4 including __________
simvastatin or lovastatin
pitavastatin
pravastatin
rosuvastatin
With CCBs use caution with other drugs that decrease HR including: ____________
beta blockers, digoxin, clonidine, amiodarone
dexmedetomidine
What are the Boxed Warnings with ACE inhibitors?
Cause injury and death to the developing fetus when used in the 2nd and 3rd trimesters; Discontinue as soon as pregnancy is detected
What are the Contraindications with ACE inhibitors?
DO NOT Use with Hx of angioedema
DO NOT Use within 36 hours of Entresto
Do Not Use with aliskiren in diabetes
What are the Warnings with ACE inhibitors?
Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (avoid use)
What are the Side effects with ACE inhibitors?
generally well tolerated, cough, hyperkalemia, increased SCr, hypotension/dizziness [increased risk if volume-depleted (with concurrent diuretic)], headache
What do we monitor for in ACE inhibitors?
blood pressure, K “potassium”, renal function, signs and symptoms of angioedema
Capoten
captopril - “12.5mg BID - 50mg TID”
Avapro *
irbesartan
Cozaar *
losartan
Benicar *
olmesartan
Diovan *
valsartan
Edarbi
azilsartan
Micardis
telmisartan
What are some benefits with ARBs over ACE inhibitors?
Less cough
Less angioedema
No washout period required with Entresto
What is an important pearl with azilsartan (Edarbi)?
Keep in original container to protect from light and moisture
What Warning does olmesartan (Benicar) have?
sprue-like enteropathy (ongoing damage or irritation and swelling to the small intestine) - severe, chronic diarrhea with substantial weight loss; can occur months to years after drug initiation.
Tekturna
aliskiren
what class of medications prevents the conversion of angiotensinogen to angiotensin I ?
Direct Renin Inhibitor
ex. Tekturna
Contraindications with Tekturna
Do NOT use with ACE inhibitors or ARBs in patients with diabetes
Pearls/Notes to know about Tekturna
Avoid high fat foods (reduces absorption)
tablets must be protected from moisture
Take with or without food but be consistent in administration with regard to meals
Dosing of Tekturna
150-300mg daily
All RAAS inhibitors have increased risk of ________
hyperkalemia. Other medications that increase potassium should be used cautiously. Patients should avoid salt substitutes that contain potassium chloride
ACE inhibitors and ARBs should NOT be used in combination with ____________. ACE inhibitors or ARBs are contraindicated with ________ in patients with diabetes
Entresto
Tekturna
MOA of Tekturna -
inhibits the conversion of angiotensinogen to angiotensin 1, therefore decreased formation of Angiotensin 1 leading to a decrease in formation of Angiotensin 2.
ACE inhibitors and ARBs can ____________ lithium renal clearance and __________ the risk for lithium toxicity
decrease lithium renal clearance
&
increase the risk for lithium toxicity
Potassium-sparing diuretics _________ and ___________ have minimal blood pressure lowering effects. They are often used in combination with HCTZ to ___________ seen with thiazide diuretics.
triamterene
amiloride
counteract the mild potassium losses
The aldosterone receptor antagonists _________ and ___________ are the preferred add-on drugs in “resistant hypertension” = (uncontrolled blood pressure despite maximum tolerated doses of a CCB + thiazide diuretic + ACE inhibitor or ARB) AND they are commonly used in ________
spironolactone and eplerenone
heart failure
which aldosterone receptor antagonist is nonselective and which one is selective?
spironolactone = non-selective aldosterone receptor antagonist (also blocks androgen)
eplerenone = selective aldosterone receptor antagonist ( DOES NOT
The potassium sparing diuretics compete with aldosterone at receptor sites in the _________ and ___________ of the nephron, increasing excretion of ________ and _______ but conserving potassium
distal convoluted tubule and collecting ducts
Na+ & H2O
Aldactone *
spironolactone tablets
CaroSpir
spironolactone oral suspension
(approved for HF and edema due to cirrhosis) is not therapeutically equivalent to Aldactone and dosing recommendations differ
Dyrenium
triamterene
Dyazide **
brand D/C triamterene/HCTZ
Maxzide *
triamterene/HCTZ
amiloride
Inspra
eplerenone
Eplerenone is a major substrate of ___________; Do NOT USE with ________
CYP3A4
CYP3A4 inhibitors
(ketoconazole, itraconazole, clarithromycin, ritonavir)
What are the Boxed Warnings with amiloride & triamterene:
hyperkalemia (K>5.5mEq/L) - more likely in patients with diabetes, renal impairment, or elderly patients
What are the Contraindications with Aldactone
Do NOT Use if hyperkalemia, severe renal impairment, Addison’s disease
What are the Contraindications with Inspra
Do NOT Use if patient taking strong CYP3A4 inhibitors
What are the side effects seen with Aldactone
increased K, (hyperkalemia), increased SCr, dizziness
gynecomastia(enlargement of breast tissue in men), breast tenderness, impotence, irregular menses
What are the side effects seen with Inspra
increased TG,
increased K (hyperkalemia), increased SCr, dizziness
What do we monitor with potassium sparing diuretics?
Blood pressure, K, renal function, fluid status, signs and symptoms of heart failure
Potassium Sparing diuretics can _________ lithium renal clearance and __________ the risk of lithium toxicity
decrease
increase
Selection of a specific Beta blocker will depend on the _____ being treated.
condition
bisoprolol, carvedilol or metoprolol succinate should be used if treating _________
chronic heart failure
MOA of Beta blockers:
they decrease BP by competitively blocking beta-1 and/or beta-2 adrenergic receptors, resulting in decreases in HR and myocardial contractility
Which beta-blockers have alpha-1 blocking properties
carvedilol & labetalol
Beta-blockers with (ISA) ____________ include: ______
intrinsic sympathomimetic activity
acebutolol, penbutolol, pindolol
Beta-blockers with ISA are NOT recommended in patients __________. They Do Not _________ heart rate to the same degree as beta-blockers with ISA
post-MI (myocardial infarction)
decrease
If a beta-blocker is needed in a patient with bronchospastic disease (asthma, COPD) a ______________ agent is preferred
beta-1 selective
Tenormin *
atenolol ——————- beta-1 selective
Brevibloc *
esmolol ————beta-1 selective
injection
Lopressor *
metoprolol tartrate ————-beta-1 selective
tablet, injection
Toprol XL *
metoprolol succinate ———– beta-1 selective
tablet
Kapspargo Sprinkle
metoprolol succinate ———-beta-1 selective
capsule sprinkle
Betoptic S
betaxolol —– beta-1 selective ophthalmic solution
also available as a tablet
Remember “AMEBBA” for Beta-1 selective beta blockers
atenolol
metoprolol
esmolol
bisoprolol
betaxolol
acebutolol
What is the beta blocker that is Beta-1 selective with Nitric Oxide-Dependent Vasodilation
Bystolic —– nebivolol
What are the Non-selective beta-blockers?
Inderal ——— propranolol
Corgard——— nadolol
pindolol
timolol
Coreg ——— carvedilol
labetalol
Inderal LA
propranolol ——— non-selective beta-blocker
Dosing: 80-160mg daily MAX: 640mg daily
Inderal XL
propranolol ——– non-selective beta-blocker
dosing: 80mg daily MAX 120mg daily
Corgard
nadolol ———— non-selective beta-blocker
dosing: 40-320mg daily
Trandate *
labetalol
Normodyne *
labetalol
Coreg *
carvedilol IR
What are the Boxed Warnings with Beta-Blockers
Do NOT discontinue abruptly (particularly in patients with CAD/IHD); gradually taper dose over 1-2 weeks to avoid acute tachycardia, hypertension, and/or ischemia
What are the Contraindications with Beta-1 selective blockers
severe bradycardia; 2nd or 3rd degree AV block or sick sinus syndrome (unless a permanent pacemaker is in place); overt cardiac failure or cardiogenic shock
esmolol- pulmonary hypertension; use of IV non-DHP CCBs
What are the Warnings with beta-blockers
Use Caution in patients with diabetes: can worsen hyperglycemia or hypoglycemia and mask hypoglycemic symptoms.
Use Caution with bronchospastic diseases (asthma, COPD), beta-1 selective preferred
Use Caution with Raynaud’s/ other peripheral vascular diseases, pheochromocytoma and heart failure (slow dose titration required if used in these conditions)
Can mask signs of hyperthyroidism (tachycardia), can worsen CNS depression
Side effects with beta-blockers
bradycardia, fatigue, hypotension, dizziness, depression, impotence (less than thiazides),
cold extremities (can exacerbate Raynaud’s)
Monitoring with beta blockers
Heart Rate, BP
(decrease dose if HR < 55 BPM)
Notes/Pearls with Beta blockers
oral drugs: titrate doses every 1-2 weeks (as tolerated), take without regard to meals (EXCEPT for Lopressor & Toprol XL, SHOULD be taken with or immediately following food)
What is the IV:PO ratio for metoprolol tartrate
1:2.5
When switching from metoprolol tartrate to metoprolol succinate, the TDD _____________
is the same and should be used
Notes/Pearls with Non-Selective Beta blockers
are used in portal hypertension
Notes/Pearls with the non-selective beta blocker propranolol
Has high lipid solubility (lipophilic) and crosses the blood-brain barrier; it is associated with more CNS side effects, but this makes it useful for other conditions (migraine prophylaxis, essential tremor)
what is the conversion ratio going from carvedilol CR to carvedilol IR
Coreg CR 10mg daily = Coreg 3.125mg BID
Dose conversions ARE NOT 1:1
Notes/Pearls with carvedilol
Take ALL forms of carvedilol with food to decrease the rate of absorption and the risk of orthostatic hypertension
Coreg CR 10mg daily = Coreg 3.125mg BID
Dose conversions ARE NOT 1:1
Contraindications with carvedilol
Severe hepatic impairment
severe bradycardia; 2nd or 3rd degree AV block or sick sinus syndrome (unless a permanent pacemaker is in place); overt cardiac failure or cardiogenic shock
Warnings with carvedilol
Intraoperative floppy iris syndrome has occurred in cataract surgery patients who were on or were previously treated with an alpha-1 blocker
which beta blockers are nonselective and are alpha-1 blockers
carvedilol
labetalol
which beta blocker is the drug of choice in pregnancy
labetalol
injection is commonly used in the hospital setting and can be administered by repeated IV push or slow continuous infusion
Hemangeol
propranolol oral solution
group 2 antiarrhythmic
Timoptic
timolol ————– non-selective beta-blocker
Beta Blocker Drug Interactions
Beta blockers can enhance the _______________ effects of insulin and sulfonylureas AND ______ some of the symptoms of _________(shakiness, palpitations, anxiety) symptoms of sweating and hunger are not masked.
hypoglycemic
mask
hypoglycemia
Beta Blocker Drug Interactions
beta blockers can _________ insulin secretion, causing _________.
decrease
hyperglycemia
Beta Blocker Drug Interactions
Use CAUTION when administering other drugs that decrease HR including _______________________
diltiazem, verapamil, digoxin, clonidine, amiodarone and dexmedetomidine (Precedex)
which beta blockers are major substrates for CYP2D6
carvedilol, propranolol, and metoprolol
which beta blockers are inhibitors of P-gp and can increase the serum concentrations of P-gp substrates like (cyclosporine, dabigatran, digoxin, ranolazine)
carvedilol & propranolol
Contraindications with Bystolic (_________)
nebivolol
Severe Liver impairment ( Child-Pugh > class B)
Catapres **
clonidine
dosing: 0.1-0.2mg PO BID. Max dose is 2.4mg daily
centrally-acting alpha-2 adrenergic agonists
commonly used for resistant hypertension
Catapres-TTS *
clonidine transdermal patch
centrally-acting alpha-2 adrenergic agonists
indicated for resistant hypertension
TTS-1 = 0.1mg/24hr
TTS-2 = 0.2mg/24hr
TTS-3 = 0.3mg/24hr
Tenex *
guanfacine IR
dosing: 1-2mg QHS
centrally-acting alpha-2 adrenergic agonists
Indicated for resistant hypertension
Intuniv *
guanfacine ER
centrally-acting alpha-2 adrenergic agonists
Indicated for ADHD
which medications are centrally-acting alpha-2 adrenergic agonists
clonidine
guanfacine
methyldopa
Apresoline *
hydralazine
vasodilator
Kapvay *
clonidine
centrally-acting alpha-2 adrenergic agonists
Indicated for ADHD
Aldomet
methyldopa
centrally-acting alpha-2 adrenergic agonists
indicated for hypertension
preferred drug in pregnancy
MOA of clonidine, guanfacine, and methyldopa
decrease blood pressure by stimulating alpha-2 adrenergic receptors in the brain and reducing sympathetic outflow of norepinephrine, which decreases SVR and HR
clonidine is commonly used for ________ and in patients who CAN NOT swallow since it is available as a patch formulation. Patch is changed ______ , it can help with adherence.
resistant hypertension
weekly
Contraindications with Methyldopa:
concurrent use with MAO inhibitors
active liver disease
Warnings with Centrally acting alpha-2 adrenergic agonists
DO NOT DISCONTINUE abruptly ( can cause rebound hypertension, sweating, anxiety, tremors) Must taper gradually over 2-4 days
Warnings with Methyldopa
risk for hemolytic anemia (detected by a positive Coombs test), hepatic necrosis
Side Effects with centrally acting alpha 2 adrenergic agonists
dry mouth, somnolence, fatigue, dizziness, constipation, decrease HR, hypotension, impotence
headache, depression, behavioral changes ( irritability, confusion, anxiety, nightmares)
clonidine patch: skin rash, pruritus, erythema
methyldopa: hypersensitivity reactions (drug-induced lupus erythematosus (DILE)), edema or weight gain (control w/ diuretics), increase prolactin levels
Notes/pearls with Catapres-TTS
remove before MRI
Apresoline *
hydralazine
direct vasodilator
Dosing: PO 10-50mg QID
MAX dose 300mg daily
IM, IV: 10-20mg Q 4-6H PRN
Rogaine for Men or Women
minoxidil
-OTC topical for hair growth
minoxidil
MOA of hydralazine
causes direct vasodilation of arterioles, with little effect on veins. The result is a decrease in SVR and reduction in BP
MOA of minoxidil
causes direct vasodilation of arterioles, with little effect on veins. The result is a decrease in SVR and reduction in BP
Blood Pressure = __________ x ___________
(SVR) systemic vascular resistance x (CO) cardiac output
Cardiac Output (CO) = __________ x ________
stroke (Blood) volume x Heart Rate (HR)
MOA of alpha-blockers =
bind to alpha-1 adrenergic receptors, which results in peripheral vasodilation of arterioles and veins. NOT RECOMMENDED for hypertension but may be used in men who have (BPH) benign prostatic hyperplasia
drugs that are alpha blockers -
doxazosin, prazosin, terazosin
Hypertensive crisis is defined as ______
rapidly accelerating blood pressure (generally >= 180/120)
What are the two types of hypertensive crisis:
1) hypertensive emergency = rapidly accelerating blood pressure WITH acute target ORGAN DAMAGE that may be life threatening (encephalopathy, stroke, acute kidney injury, acute coronary syndrome)
2) hypertensive urgency - no evidence of acute target organ damage
Treatment of Hypertensive Emergency:
Treat with IV medications
Decrease Blood Pressure by no more than 25% within the first hour, then if stable, decrease to ~160/100 mmHg in the next 2-6 hours
Treatment of Hypertensive Urgency:
Treat with any oral medications that has a short onset of action (15-30min)
Decrease Blood pressure gradually over 24-48 hours
What are some of the KEY IV hypertensive medications for Hypertensive Emergency?
Labetalol Nicardipine Metoprolol tartrate
Diltiazem Verapamil
Hydralazine Propranolol
Chlorothiazide Clevidipine
Nitroglycerin Nitroprusside
Enalaprilat Esmolol
All Hypertensive products:
Can cause Orthostasis ( a decrease in blood pressure that happens soon after standing or sitting up)
check your blood pressure regularly
Take blood pressure medications as directed, even if you feel well. Lowering blood pressure helps decrease risk of complications such as heart disease, kidney disease and stroke.
Thiazide-Type diuretics Counseling/Key points
Take this medication early in the day ( no later than 4pm) to avoid getting up at night to go to the bathroom.
Can cause:
-Hyperglycemia
-Photosensitivity
-Sexual dysfunction
Calcium Channel Blockers Counseling/Key points
Can cause:
-peripheral edema
-gingival hyperplasia
Adalat CC: take on an empty stomach
ghost tablet in the stool (Adalat CC and Procardia XL)
ACE inhibitors, ARBs, Aliskiren Counseling/Key points
Avoid in pregnancy (teratogenic)
Allergy/anaphylaxis (angioedema)
Ace inhibitors: dry, hacking cough
Beta-blockers Counseling/Key points
DO NOT discontinue abruptly without consulting your healthcare provider
This medication can mask symptoms of low blood sugar. If you have diabetes, check blood sugar if you notice sweating or hunger.
Can cause sexual dysfunction.
Coreg/Coreg CR - take with food
Lopressor/Toprol XL - take with food or immediately after meals
Counseling/Key points for Clonidine
Do NOT discontinue without consulting your healthcare provider
patch: apply weekly to upper outer arm or chest The white adhesive cover can be applied over the patch to keep it in place. Remove before an MRI
can cause sexual dysfunction
