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PC 707 Pharmacology > Module 4 Unit A: Anti-Hypertensives > Flashcards

Module 4 Unit A: Anti-Hypertensives Flashcards

1
Q

What is an example of a thiazides and what is their MOA? When does it peak?

A

Hydrochlorothiazide (HCTZ)

Reduce blood volume and arterial resistance by promoting Na and H2O excretion and inhibition of Na reabsorption.

Peak: 4-6hrs

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2
Q

What are the indications for HCTZ?

A 
Add on agents-to potentiate effectiveness of other agents
HTN
HF
Edema
Bone-loss in post-menopausal women
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3
Q

What Side effects do Thiazides (HCTZ) and Loop Diuretics (Furosemida) share?

A

Fluid and electrolyte loss is the largest concern!

↓K+/↓Na (more common in women), ↓Cl, ↓Mg

Hyperuricemia [gout-more common in men], hyperglycemia [DM], ↑Ca

↑ LDL/total chol, ↓HDL

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4
Q

What drugs/conditions should Thiazides (HCTZ) not be prescribed with? What conditions?

A

**Digoxin (hypokalemia=toxic arrhythmias)

Also: sulfas, K+ sparing drugs, lithium (toxicity risk), antihypertensive, NSAIDs

Conditions: renal impairments/hypokalemia

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5
Q

What is an example of a Loop Diuretic and with is its MOA?

A

Furosemide (Lasix)

MOA: inhibits reabsorption of Na and Cl in loop of Henle (rapid onset o:60m, IV:5m)

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6
Q

What adverse effects are associated with Loop Diuretics (Furosemida) but not Thiazides (HCTZ)? Drug to Drug interaction specific to Loop Diuretics? Contraindications?

A

Specific to Loop: Hypotension and ototoxicity. Higher risk fo electrolyte imbalance and dehydration (due to higher potency)

D2D: Ototoxic drugs

Contraindications: Anuria

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7
Q

What is the BBW associated with Loop Diuretics?

A

Profound diuresis with water and electrolyte depletion

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8
Q

What are the indications for Loop Diuretics (Furosemide)?

A

Pulmonary edema from HF
Edema (cardiac, hepatic, renal origin)
HTN unresponsive to other diuretics (due to ability to work with low GFR)

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9
Q

What monitoring and education should occur with a patient on Loop Diuretics (Furosemide)?

A

Monitor electrolytes and BP. Add PO K+&Cl when indicated.

Educate slow transition from lying > to sitting > to standing

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10
Q

What is an Osmotic Diuretic?

A

Mannatol

We will not be using this in primary care. Just know it exists

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11
Q

What are our Potassium-Sparing Diuretics?

A

Aldosterone antagonist (spirinolactone) and Nonaldosterone antagonist (trimatrene or amiloride)

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12
Q

How does the Potassium-sparing diuretic: Aldosterone antagonist (spirinolactone) work? How is it typically given?

A

Blocks aldosterone in the distal nephron, retains K+, excretes sodium=fluid loss

Typically paired with other diuretics

Slow onset:1-2 days

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13
Q

What is the Potassium-sparing diuretic: Aldosterone antagonist (spirinolactone) used for?

A

Key: Refractory HTN, edema, HF

Also:hyperaldosteronism, PMS, PCOS, acne in women

↓mortality and hospital admissions in HF.

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14
Q

What are the adverse effects associated with Potassium-sparing diuretic: Aldosterone antagonist (spirinolactone)? Contraindications?

A

Hormonal: gynecomastia, ED, post-menopause bleeding.

Hyperkalemia, N/V, diarrhea, gout, stomach cramps, benign tumors

Hyperkalemia (K+>5.5)

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15
Q

What is the BBW associated with the Potassium-sparing diuretic: Aldosterone antagonist (spirinolactone)?

A

Tumorigenic in rats.

Hyperkalemia

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16
Q

What D2D interactions should we be aware of with the Potassium-sparing diuretic: Aldosterone antagonist (spirinolactone)?

A

Thiazide and loop diuretics, agents that raise K+

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17
Q

How does the Potassium-sparing diuretic: Nonaldosterone antagonist (triamterene and amiloride) work? Onset?

A

disrupts Na-K+ exchange in the distal nephron, inhibits exchange mechanism, decreases Na reuptake, inhibits ion transport

Onset in hours

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18
Q

What are the adverse effects associated with Potassium-sparing diuretic: Nonaldosterone antagonist (trimaterene and amiloride)?

A

Hyperkalemia, leg cramps, nausea, vomiting, dizziness, blood dyscrasias (rare)

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19
Q

What is the Potassium-sparing diuretic: Nonaldosterone antagonist (trimaterene and amiloride) used for?

A

HTN, edema

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20
Q

What electrolyte abnormalities can occur with the diuretics?

A

**Hypokalemia- eat high-potassium diet.
Hyponatremia

Hyperglycemia-caution with DM
Hyperuricemia-gouty attack.
Hypertriglyceridemia, hypercholesteremia,

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21
Q

What is the BBW associated with Potassium-sparing diuretic: Nonaldosterone antagonist (trimaterene and amiloride)?

A

**Hyperkalemia

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22
Q

What is an example of Angiotensin-converting enzyme inhibitors
(ACEIs); and what is their MOA?

A

PRIL: lisinopril, enalapril, captopril

Block conversion of angiotensin I to II by inhibiting angiotensin converting enzyme. (inhibits vasoconstriction)

Inhibits bradykinin

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23
Q

What are the indications for ACEIs (-prils)?

A

HTN
HF
Non-diabetic nephropathy
Post-MI

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24
Q

What is the BBW associated with ACEIs (-prils)?

A

Fetal Injury: discontinue in pregnancy: ↑ 2nd and 3rd-trimester fetal harm

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25
Q

What side effects are associated with ACEIs (-prils)?

A

**ACE cough [↑ bradykinins-twice as likely in women],
Hyperkalemia [check 1-2 and periodically],
Angioedema [↑ bradykinins-↑risk for AA and women]
Stop in pts work worsening end-stage CKD and refer out

Concurrent use with trimethiprim-sulfamethoxazol or ARB increase risk of hyperkalemia and sudden death

First dose hypotension
NSAIDs ↓antihypertensive effects

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26
Q

What is the most common side effect for ACEIs (-prils)? Who is at increased risk? How do we manage/treat it?

A

ACEI Cough (bradykinins)

Increased risk: ↑ age, female sex, and Asian ancestry.

Stop ACEI and switch to ARB

27
Q

What is an example of Angiotensin-2 receptor blockers

(ARBs); and what is their MOA?

A

-SARTAN: losartan

Block angiotensin receptor sites in blood vessels (vasodilation)

28
Q

What BBW is associated with ARBs (-sartan)?

A

Fetal Injury: discontinue in pregnancy: ↑ 2nd and 3rd-trimester fetal harm

29
Q

What side effects are associated with ARBs (-sartans)?

A

Hyperkalemia, Angioedema, Decrease in renal funct.

Monitor renal funct and K+

Serious SE: Dizziness, postural hypotension, and severe hypotension with reflex tachycardia

30
Q

What are the indications for ARBs (-sartan)?

A

HTN-as effective as ACEI but do not act on bradykinin
HF
Renal protective in DM
Benign hypertrophy

31
Q

Drugs that prolong QT?

A

Amioderone, Sotalol, Flecainide, Procainamide, Quinidine

32
Q

Do ARBs (-sartans) increase bradykinins in the lungs? Why?

A

NO

Does not inhibit kinase II

33
Q

What is an example of Calcium channel blockers (DHPs); and what is their MOA?

A

Nifedipine (Procardia)

Inhibit movement of calcium channel ions across the membranes and dilate arteries/decrease force of contraction. DHPs act in periphery causing arterial vasodilation

34
Q

What are the indications for Calcium channel blockers (DHPs) [Nifedipine]?

A

1st choice for Black people

HTN
Vasospastic angina
Migraine

35
Q

What side effects are associated with Calcium channel blockers (DHPs) [Nifedipine]? Any age conisderations?

A

Reflex tachycardia (nifedipine), flushing, dizziness, HA, peripheral edema (pedal edema more in men), gingival hyperplasia

May cause a chronic eczematous rash in older adults.

36
Q

What are the indications for Calcium channel blockers (non-DHPs) [Verapamil/Cardizem]?

A

HTN
Angina (decrease O2 demand)
Cardiac dysrythmias
migraine prevention

37
Q

What is an example of Calcium channel blockers (non-DHPs); and what is their MOA?

A

Verapamil, Cardizem

Inhibit movement of calcium channel ions across the membranes and dilate arteries/decrease force of contraction. Act centrally to reduce HR and contractility.

38
Q

What side effects are associated with Calcium channel blockers (non-DHPs) [Verapamil]? Any age considerations?

A

HA, constipation, dizziness, facial flushing, edema of ankles/feet, bradycardia.

Elderly: severe constipation and eczema.

39
Q

What medications may need to be avoided with Calcium channel blockers (non-DHPs) [Verapamil]? Foods?

A

β-adrenergic blockers (potentiate SE)

Grapefruit juice

caution with digoxin-verapamil increases plasma levels

40
Q

What is an example of Beta-Blockers; and what is their MOA?

A

-OLOL
Propranolol (1st gen, nonselective)
Metoprolol (2nd gen, cardioselective)

MOA:Block central and peripheral beta receptos to decrease CO and sympathetic outflow. Blocks epinephrine and slows heart rate and force.

41
Q

What are the indications for Beta-Blockers (-olols)?

A 
HTN
Migraines
Management of MI
Hyperthyroidism symptoms
Public speaking/"Stage Fright"
42
Q

What side effects are associated with Beta-blockers (-olols)? Contraindications?

A

Worsened depression
Rebound HTN
Use cautiously: DM (Can worsen or mask hypoglycemia)

Asthma, COPD, bronchitis and emphysema choose Metropolol (no beta2 blocking).

Contraindication: Contraindicated: 2nd and 3rd degrees heart block and bradycardia (<45bpm)

43
Q

What BBWs are associated with Beta-blockers (-olols)?

A

Cardiac ischemia with abrupt discontinuation-taper over 1-2 weeks

44
Q

Why should Beta-Blockers (-olols) be tapered off?

A

To avoid rebound cardiac HTN or ischemia.

Taper over 1-2 weeks

45
Q

What is an example of Vasodilators; and what is their MOA?

A

Hydralazine (Apresoline)

MOA: Relax the smooth muscle in the blood vessels. Reduces systemic vascular resistance.

Increased renal blood flow and cardiac output

46
Q

What are the indications for Vasodilators (Hydralazine)?

A

HTN
HF

Use in combinations with b-blocker or diuretic-not very effective alone

47
Q

What medications are vasodilators (hydralazine) usually prescribed with for HTN and HF?

A

Usually with a β-adrenergic blocker for HTN

Usually, with isosorbide dinitrate for HF

48
Q

What side effects are associated with Vasodilators (Hydralazine)?

A

Orthostatic hypotension (lightheadedness, dizziness), reflex tachycardia (educate to change positions slowly)

Lupus like syndrome

49
Q

What is angioedema and what population is at increased risk?

A

Angioedema is a rare but potentially fatal adverse effect of ACE inhibitors and is significantly more common in Black patients due to their increased sensitivity to bradykinin. Angioedema is swelling (usually localized) of the subcutaneous tissues due to increased vascular permeability and extravasation of intravascular fluid.

50
Q

What antihypertensives must be avoided in pregnany?

A

ARBs, direct renin inhibitors, ARNI, ACE-I can cause fetal injury-BBW (Drugs that act directly on the renin-angiotensin system can cause injury and death to the developing fetus.)

Mineralocorticoid antagonists and statins are contraindicated during pregnancy due to unknown effects and safety issues.

51
Q

What drugs are safe in pregnancy?

A

ACOG: Labetalol (Beta-blocker), **nifedipine(CCB DHP), **methyldopa, and Hydralazine (vasodilator)

Last line:Diuretics (lasix)and Thiazides (HCTZ) due to volume reduction.

52
Q

Which class of antihypertensives binds to steroid hormone receptors? What are the potential side effects of this?

A

Aldosterone Receptor Antagonists or Potassium-sparing Diuretic- spironolactone (Aldactone)

Hormonally-influenced side effects:, such Gynecomastia, post-menopausal bleeding, and erectile dysfunction.

Hyperkalemia, vomiting, diarrhea, gout, and stomach cramps. Contraindications to aldosterone receptor antagonists include hyperkalemia (K+> 5.5mEg/L).

53
Q

What angiotensin-converting enzyme inhibitors and angiotensin receptor-neprilysin inhibitors can be combined to treat hypertension?

A

**Thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin-2 receptor blockers (ARBs).

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin-2 receptor blockers (ARBs) should not be used simultaneously.

54
Q

For what comorbid conditions should beta-adrenergic blockers be used cautiously and why?

A

Asthma, chronic obstructive pulmonary disease, chronic bronchitis, and emphysema, as non-cardioselective beta-blockers can cause bronchoconstriction.

55
Q

What is the main difference between the DHPs and the non-DHP calcium channel blockers?

A

Dihydropyridine (DHPs)-nifedipine (Procardia): act predominantly in the periphery causing arterial vasodilation

Non-dihydropyridine (non-DHPs[calcium channel blockers[verapamil] act predominantly centrally (think the heart) to decrease heart rate (chronotropy) and decrease contractility (inotropy).

56
Q

Which antihypertensives can lead to erectile dysfunction?

A

Beta-adrenergic blockers, thiazides, and spironolactone

57
Q

What are the QT prolongers for module 4?

A

Amiodarone, Sotalol, Flecainide, Procainamide, Quinidine

58
Q

How can we prescribe to better ensure patients are compliant?

A

Use once-daily drug dosing or combination therapy

59
Q

What effects can NSAIDs have on blood pressure? Who/what should we avoid them with?

A

Can elevate BP. Especially if used with ACE/Aldosterone receptor blockers

Avoid in HF-can worsen

60
Q

What medications discussed can elevate BP?

A

Pseudoephedrine andmethylphenidate (decongestants), non-steroidal anti-inflammatories drugs & COX-2inhibitors, corticosteroids, central nervous stimulants (caffeine), estrogens & progestins,selective norepinephrine receptor inhibitors (venlafaxine), immunosuppressants (cyclosporine and tacrolimus), atypical antipsychotics (clozapine, olanzapine), alcohol,herbal supplements (ma hung/ephedra, ginseng; St. John’s Wort with MAO inhibitors),recreational drugs (cocaine and methamphetamines).

61
Q

What agents can be used in pediatric patients with HTN?

A

ACEI, ARB, CCB, or Thiazide

f/u every 4-6wks

62
Q

Can HCTZ be used in lactation?

A

Yes it is considered safe, but high doses can effect milk supply

63
Q

Which classes of antihypertensives are more and less effective in the Black patient population?

A

MORE: CCB and diuretics
LESS: ACE inhibitors and beta-blockers

64
Q

Why should beta-adrenergic blockers and calcium channel blockers typically not be combined?

A

May result in heart block or bradycardia.

PC 707 Pharmacology (39 decks)

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