In depth HTN pharm Flashcards
1
Q
Thiazide Diuretics- 4
A
Hydrochlorothiazide/HCTZ (Hydrodiuril)
Chlorthalidone (Diuril)
Indapamide (Lozol)
Metolazone (Zaroxolyn)
2
Q
Thiazide AE’s:
A
- Electrolyte abnormalities: hyponatremia, hypokalemia, hypomagnesemia, hypercalcemia, contraction alkalosis
- Gout, hyperuricemia
- Hyperglycemia, worsening DM
- Hypovolemia (overdiuresis)
3
Q
Thiazide Dosing?
A
AM dosing
4
Q
Thiazide MOA:
A
increasing renal excretion of sodium and may have some vasodilator effects
5
Q
Diuretics are most effective when combined with:
A
ACEI or ARBs, may be used with CCBs
6
Q
Clinical outcome benefits (reduction of strokes and major cardiovascular events) have been best established with:
A
chlorthalidone, indapamide, and to a lesser extent with hydrochlorothiazide
7
Q
clinicians should avoid prescribing thiazides first line in:
A
diabetics
8
Q
newly started on a thiazide or a thiazide like diuretic or if prescribed a dosage increase should have this lab:
A
electrolyte panel checked within 10-14 days of initiation to evaluate for:
Hypokalemia and Hyponatremia
9
Q
Benefits of using Clorthalidone:
A
CV events were significantly less common and SBP and LDL cholesterol levels were lower
10
Q
Loop Diuretics- 3
A
Furosemide (Lasix)
Bumetanide (Bumex)
Torsemide (Demadex)
11
Q
Loop dosing?
A
AM or afternoon dosing
12
Q
Loop AE’s:
A
Hyponatremia, hypokalemia, hypomagnesemia, hypocalcemia, hyperuricemia, hyperglycemia, overdiuresis
13
Q
Higher Loop Doses for:
A
for pts with severely decreased glomerular filtration rate, if the patient is accustomed to med or heart failure
14
Q
Potassium-Sparing Diuretics- 2
A
- Triamterene (combo w/ HCTZ is Dyazide or Maxzide)
- Spironalactone (Aldactone)
15
Q
Potassium-Sparing Diuretics dosing?
A
AM or afternoon dosing
16
Q
Potassium-Sparing Diuretics AE’s:
A
- Hyperkalemia especially in combination with an ACE inhibitor, ARB or potassium supplements
- Avoid in patients with CKD or diabetes
17
Q
Potassium-Sparing Diuretics often used in conjunction with _______ and increases risk for __________
A
thiazide; hyperkalemia
18
Q
Aldosterone Antagonists- 2
A
Eplerenone (Inspra)
Spironolactone (Aldactone)
19
Q
Aldosterone Antagonists AE’s:
A
- Hyperkalemia especially in combination with ACE I, ARB or potassium supplements
- Avoid in CKD or DM patients
- Gynecomastia and impotence (spironolactone > eplerenone)
- Due to risk of hyperkalemia, eplerenone used cautiously in CrCl < 50 mL/min & T2DM & proteinuria
20
Q
Angiotensin Converting Enzyme (ACE) inhibitors- 5
A
Quinapril (Accupril) Ramipril (Altace) Benazepril (Lotensin) Enalapril (Vasotec)* Lisinopril (Prinivil, Zestril)
21
Q
ACE-inhibitors tx of choice in patients with:
A
hypertension, chronic kidney disease, and proteinuria
22
Q
ACE-inhibitors reduce Morbidity and mortality in:
A
HF, recent MI
- Halt or may regress remodeling in LVH
23
Q
ACE-inhibitors MOA:
A
- blocking conversion of ang I to ang II (a potent vasoconstrictor) & block activation of RAAS
- Also inhibits the breakdown of bradykinin, a potent vasodilator
24
Q
ACE-inhibitors require monitoring:
A
serum K+ & Cr within 2 weeks of initiation or dose increase. Must be stopped if hyperkalemia or increasing serum creatinine
25
ACE-inhibitors AE's:
```
Dry cough: may occur at any time
20-25% of pts and due to increased bradykinin, more common in women, AA, Asians
Angioedema: more common in blacks
Hyperkalemia: particularly in CKD or DM
C/I in pregnancy
```
26
ARB's- 6
```
Losartan (Cozaar)
Candesarten (Atacand)
Valsartan (Diovan)
Olmesartan (Benicar)
Telmisartan (Micardis)
Irbesartan (Avapro)
```
27
ACE-I and ARBS are most effective in:
whites and Asians and less effective in blacks
28
ARB's MOA:
stop the vasoconstricting effect of angiotensin II by blocking it’s receptor
29
ARB's preferred over ACE's when:
IF insurance coverage available because they cause less cough and have a lower risk of angioedema
30
ARB's C/I:
- pregnancy, and need to monitor renal status and potassium when initiating
- contraindicated with h/o ACEI associated angioedema
31
ACE/ARB's used together:
Combination therapy reduces proteinuria more than monotherapy but worsens major renal outcomes
32
Direct Renin Inhibitor- 1
Aliskiren (Tekturna)
33
DRI MOA:
Inhibits conversion of angiotensinogen to angiotensin I
34
DRI efficacy demonstrated in combination with:
amlodipine, HCTZ, but not for use with ACEI/ARB
35
DRI AE's:
- orthostatic hypotension, hyperkalemia
| - Does not block bradykinin breakdown; less cough than ACE Inhibitors
36
CCB MOA:
Inhibit influx of Ca2+ across cardiac and smooth muscle cell membranes resulting in coronary and peripheral vasodilation
37
DHP MOA:
block calcium channels in the vasculature
38
Non-DHP MOA:
block cardiac calcium channels primarily
39
DHP-3
Amlodipine (Norvasc)
Felodipine (Plendil)
Nifedipine (Procardia, Adalat)
40
Non-DHP-2
Diltiazem (Cardizem, Tiazac)
| Verapamil ( Calan)
41
DHP MOA:
Potent arteriolar vasodilators with no effect on AV nodal conduction
42
non-DHP MOA:
Decrease HR by blocking the SA and AV nodes, used to slow Av nodal conduction may treat supraventricular tachyarrhythmias
43
DHP AE's:
- baroreceptor-mediated reflex tachycardia due to potent vasodilating effects (avoid SA forms)
- worsens peripheral edema (bc increases vascular permeability; less common w/ DRI adm.)
- flushing, lightheadedness, dizziness, and HA in 10- 20%
44
non-DHP AE's:
- bradycardia
- AV block
- systolic HF (may cause or worsen edema)
- concurrent use with BB
45
Verapamil and to a lesser degree diltiazem known to:
decrease cardiac contractility and heart rate; should not be used with a BB or in bradyarrhythmias (SSS, 2nd/3rd AVB)
46
SA CCB's known to:
worsen HF and should not be used in patients with decompensation
(Long-acting are safe)
47
Verapamil alone known to cause:
constipation
48
CCB overdose:
- seen in pts ingesting 5-10x the standard dose
- cardiac depression and bradycardia
- clear mentation, but neuro status can decline rapidly
- EKG: prolonged PR interval and bradyarrythmias
- hyperglycemia (inhibition of calcium release)
- remainder of lytes normal; check tox screen
49
CCB overdose and tx
- IVF resuscitation and atropine for bradycardia
- GI decontamination (AC)
- admin. of IV calcium
- glucagon
- pressors (norepi)
- high dose insulin therapy
50
β1 receptors located and stimulation effects?
- heart and kidney
| - increases HR, contractility, and renin release
51
β2 receptors located and stimulation effects?
- lungs, liver, pancreas, arteriolar smooth muscle
- bronchodilation and vasodilation
- mediate insulin secretion and glycogenolysis
52
BB MOA:
block cardiac beta 1 receptors reducing responsiveness to sympathetic activity and may also target beta 2 receptors in the lungs if they are non-cardioselective or if given at high doses
53
BB used cautiously w/:
asthma or chronic obstructive pulmonary disease (COPD), regardless of beta-selectivity profile
54
BB not recommended 1st line in tx for:
HTN except in the case of a compelling cardiac indication; post-MI, or heart failure (symptomatic or asymptomatic LV dysfxn)
55
BB least effective in this ethnicity:
AA
56
BB have a ADR w/ and are not recommended in what population?
- glucose metabolism, especially when combined with a diuretic
- block awareness of hypoglycemia
- not recommended in diabetics (unless compelling indication)
57
Main AE's w/ BB:
- reduced sexual function, fatigue, and reduced exercise tolerance
- may also precipitate heart block or bradyarrhythmias
58
Cardioselective BB: 4
Bisoprolol (Zebeta)
Metoprolol succinate (Toprol XL)
Metoprolol tartate (Lopressor)
Atenolol (Tenormin)
59
Non-selective: 2
Nadolol (Corgard)
| Propranolol (Inderal)
60
Non-selective MOA BB:
Inhibit β1 and β2 receptors at all doses
61
Cardioselective BB safer in ___________ and more helpful to gain control of ____________
- PAD, DM and COPD
| - tachyarrhythmias (atrial fib or sinus tachycardia)
62
Beta blockers must be started:
- started low dose and dose titrated cautiously in LV dysfunction and HFrEF due to their myocardial depressive effects
- should not be abruptly discontinued if possible, since this may cause rebound HTN, worsening angina or MI. If able, slowly wean dose down over 1-2 weeks
63
BB are NOT recommended in pts:
>60 y.o.
64
Mixed- 2
Carvedilol (Coreg)
| Labetolol (Trandate)
65
Mixed AE's associated w/ more:
orthostatic hypotension (lowers standing BP more than supine BP)
66
Mixed MOA:
Block β receptors (decrease HR) and α1 receptors (peripheral vasodilation)
67
Mixed reduces mortality in pts w/:
systolic HF treated with diuretic and ACE inhibitor
68
Carvedilol (Coreg) MC used in and specifics:
BP lowering in patients with HF or DM
| - less effect on glucose metabolism
69
Labetolol (Trandate) MC used:
- Oral/IV BP lowering
| - Used in pregnancy
70
alpha-1 blockers- 3
Prazosin (Minipress)
Terazosin (Hytrin)
Doxazosin (Cardura)
71
alpha-1 blockers MOA:
- blockade of alpha-1 causes peripheral vasodilation and BP lowering
- blocks alpha-1 receptors on the prostate, allowing for easier urine flow
72
alpha-1 blockers AE's:
- Orthostatic hypotension
- 1st dose phenomenon: transient dizziness, faintness, palpitations, syncope within 1 to 3 hours of 1st dose
- Edema, may give with a diuretic, but monitor for orthostasis
73
alpha-1 blockers caution w/:
elderly (greater tendency for orthostasis)
74
alpha-1 blockers dosed at:
bedtime
75
Central alpha-2 agonists: 2
Clonidine (Catapres)
| Methyldopa (Aldomet)
76
Central alpha-2 agonists MOA:
- Stimulate α2-adrenergic receptors in the brain: reduces sympathetic outflow from the CNS and increases vagal tone (decrease HR and vasculature tone)
- Peripheral stimulation of presynaptic α2-receptors: may further reduce sympathetic tone
- Decreases epinephrine and sympathetic tone
77
one of the safest drugs to use in pregnant HTN:
methyldopa (aldomet)
78
this drug directly counteracts the sxs of etoh withdrawal
clonidine (catapres)
79
Clonidine dosage benefits and target populations:
- given by patch once weekly (pts w/ compliance issues)
- safe in renal failure and frequently used in ESRD pts with severe/refractory HTN
- alcohol withdrawal
80
Central alpha-2 agonists AE's:
- Sodium/water retention leading to edema
- Orthostatic hypotension
- Dizziness
- Clonidine: rebound HTN and anticholinergic SE (dry mouth, constipation, flushing)
81
Direct Arterial Vasodilators: 2
hydralazine (aspresoline)
| minoxidil
82
Direct Arterial Vasodilators AE's:
- Edema (may use with diuretic (loop) in order to minimize)
- Angina (caution w/ CAD)
- Reflex tachycardia (may use with BB)
- Hydralazine is known to cause drug induced lupus
- Excessive hair growth with minoxidil
83
Direct Arterial Vasodilators MOA:
Direct arterial smooth muscle relaxation causes antihypertensive effect (with little/no venous vasodilation)
84
Minoxidil often used for:
renal failure pts. w/ difficult HTN
85
Hydralazine often used for:
used IV to control BP (HR neutral), combo w/ HF and CKD patients (safe w/ renal failure)
86
Non-selective BB Uses:
HTN- migraine prophylaxis, essential tremor, portal HTN, thyrotoxicosis
87
If stopped abruptly, clonidine can lead to:
Hypertensive urgency or emergency
87
TZD’s should not be used in:
Age>80; hyponatremia; SSRI; gout; urinary incontinence
88
Alpha-1 blockers Uses:
Comorbid BPH and HTN
89
Mixed alpha/beta blockers reduce mortality in pts w/:
Systolic HF treated w/ diuretic and ACE-I
90
Cardiospecific BB concern with high doses?
Loss of B1 selectivity (ask pt about COPD/asthma)
