Module 7: (b) Initial HTN Meds Flashcards
ACE Inhibitors (“pril”) -Common Drugs
- Lisinopril (Very commonly used)
2. Captopril (Short-acting) (Not used commonly in primary care)
ACE Inhibitors (“pril”) -Adverse Effects
- Cough (up to 20% of patients)
- HYPERKALEMIA **
- Teratogenic AVOID in pregnancy
- ANGIOEDEMA (Avoid w/ hx of Angioedema
ACE Inhibitors (“pril”) -African American Considerations?
- AA’s may not have substantial BP lowering w/ ACEi
- AA are 5x greater risk of Angioedema
—Educate Pt to seek ER care if they experience s/s of Angioedema - Research has shown that ACEi and CCB combo had powerful benefits in AA patients
ACE Inhibitors (“pril”) -When to Use?
- Proteinuric CKD
- HFrEF
- Post-MI
ACE Inhibitors (“pril”) -Monitoring?
- ACEi can cause INCREASE in serum creatinine
- may be benign or significant - Recheck renal function within 4 weeks. Sometimes Much sooner
Individuals at High risk include:
- Bilateral renal artery stenosis
- Hypertensive nephrosclerosis
- Polycistic kidney dz, HF, and CKD
ACE Inhibitors (“pril”) -Baseline Labs to Monitor?
- Baseline and periodic BP
- Serum Creatinine
- Electrolytes ESP POTASSIUM for Hyperkalemia
If Patient is on diuretic, start ACE at a lower dose (50%)
ACE Inhibitors (“pril”) -When to Discontinue
- DC if serum Creatinine increases more than 30% above baseline
- REFER to nephrology
ACE Inhibitors (“pril”) -Education?
- Start a BP log outpatient
2. Monitor development of dry cough
Angiotensin II Receptor Blockers “sartan”
-Common Meds?
- Losartan (Most common in Primary care)
Angiotensin II Receptor Blockers “sartan”
-Info
- No bradykinin-mediated cough like ACEi
- DO NOT combine ARB w/ ACEi
- Considered an alternative to ACEi
Angiotensin II Receptor Blockers “sartan”
-Potential Adverse Reactions?
- Hyperkalemia (similar to ACEi)
- Teratogenic —avoid in pregnancy
- Can cause changes in renal function including AKI
- Hypotension (More than ACEi)
Angiotensin II Receptor Blockers “sartan”
-Benefits
- No cough — better than ACEi for Asthma and COPD patients
- Lower incidence of Angioedema
- Enhanced uric acid secretion in gout (Particularly losartan)
Angiotensin II Receptor Blockers “sartan”
-Monitoring
- BP, Serum Cr, electrolytes (esp. Potassium for Hyperkalemia)
- DC w/ significant deterioration of renal function 30% above baseline and Consult Nephrology
- If patient is on a diuretic, elderly, or volume depleted reduce dose by 50% *
CCB
-Two major classes?
- Di-hydropyridines (Used more often for HTN)* (Better option for asthma or COPD)*
- Non-dihydropyridines
- CCB’s are effective for BLACK ethnicities, older adults
- Used in angina
CCB Di-hydropyridines “pines”
-Exemplars
- Amlodipine (Norvasc)(Most commonly prescribed)
Nifedipine (Procardia) - Long-acting agents preferred
- Short acting agents have concern for reflex Tachycardia
CCB Di-hydropyridines
-MOA
- Di-hydropyridine CCB do NOT affect conduction through the AV node
CCB Non-dihydropyridines
-Exemplars & MOA
- Diltiazem (Cardizem)
- Verapamil (Calan)
- Affect conduction through the AV node AND have negative chronotropic effects
- Used for rate control in atrial fib
CCB Di-hydropyridines
-Adverse Effects
- Peripheral Edema (Up to 20-30%)
2. CCB/ACE combo can decrease peripheral edema by 50% vs CCB high-dose alone
CCB Non-dihydropyridines
-Adverse Effects
- Constipation (Up to 25%)
- Bradycardia and AV block
AVOID in:
-HFrEF, SSS, 2nd and 3rd degree AV block
Monitor BP, HR, LFT’s and ECG
Beta Blocker + Non-dihydropyridine CCB
-Interaction?
- Potential negative additive CV effects
- HYPOTENSION
- Bradycardia
- AV Block & conduction defects
Verapamil
-Meds that interact and should avoid?
- Verapamil interacts with
- Lovastatin/Simvastatin (INcrease risk of rhabdo)
- Lithium
- Phenytoin
- Amiodarone
- Codeine
Amlodipine interacts w/ simvastatin
Thiazide Diuretics
-Exemplars
- Hydrochlorothiazide (HCTZ)
- Chlorthalidone (Thiazide-like diuretic) (Longer acting and more potent than thiazide. Increase risk of Hypokalemia)
- indapamide (Thiazide-like diuretic (Longer acting and more potent than thiazide. Increase risk of Hypokalemia)
- Additional benefit in osteoporosis
- Avoid in gout
Thiazide Diuretics
-Chlorthalidone?
- Has been shown to be superior to HCTZ
- Reduces CV events
- Considered longer-acting and more potent
Thiazide Diuretics
-Adverse effects
- Hypokalemia (More common with chlorthalidone than HCTZ
- Hyponatremia
- Hypotension
- Hyperlipidemia
- Hyperglycemia
- Hypercalcemia; HypoMagnesemia
Monitor:
- Serum Cr
- electrolytes (esp K and Na); BP
Potassium-Sparing Diuretics
-Exemplars of MRA’s
- Spironolactone
- Eplerenone
- Used for Heart Failure and RESISTANT HTN**
- Potential AE:
- Hyperkalemia - Monitor:
- Cr
- Electrolytes (Esp Potassium)
Loop Diuretics
-Exemplars and monitoring
- Furosemide
- Bumetanide
- Torsemide
—Monitor potassium. Each can lower potassium
Beta Blockers
-Cardioselective
- Atenolol
- Bisoprolol
- Metoprolol
- Esmolol
- Acebutolol
Beta Blockers
-Non-Cardioselective
- Propranolol
- Timolol
- Nadolol
Beta Blockers
-Mixed alpha/beta-blocker?
- Carvedilol
2. Labetalol
Beta Blockers
-Elderly
- Not recommended for initial therapy in a sense of specific indication
- NOT for people >60yrs old
- > 60 yrs old
- Inferior protection against CVA risk
- Small increase in mortality
Beta Blockers
-Adverse Effects
- Hypotension
- Bradycardia**
- Impaired glucose tolerance
- Fatigue, depression, and sexual dysfunction
- AVOID ABRUPT CESSATION***
- Can cause Acute MI or angina
Beta Blockers
-Indications?
- HFrEF (certain BB)
- Chronic stable angina
- Migraine prevention
- Hyperthyroidism
- Essential tremor
- Rate control w/ Atrial Fibrillation
Beta Blockers
-When to AVOID?
- Bronchospastic Dz (Asthma, COPD)
- Bradycardia
- 2nd or 3rd degree AV block
- Decompensated HF
- Caution in Diabetes
- BB + Non-dyhydropyridine CCB = NEGATIVE additive CV effects (hypotension)
Direct Renin Inhibitor
-Exemplar and Important Info
- Aliskiren (Tekturna)
- DO NOT combine w/ ACEi or ARB
- DO NOT combine w/ ARNI (used for HF)
- AVOID Pregnancy
Similar to ACEi and ARB’s
Peripherally-Acting Agents
-Alpha Blockers Exemplars
- Doxazosin, Prazosin, Terazosin
- Not a first-line antihypertensive
- Careful BP monitoring
- Can be used for PTSD and nightmares but CONSIDER Hypotension since it is a HTN medication first
Peripherally-Acting Agents
-Alpha Blockers Adverse effects
- Orthostatic Hypotension
- FIRST DOSE at bedtime
- Not given to older adults due to risk of Orthostatic hypotension
- Titrate slowly over several weeks
Centrally-acting Agents: Alpha Agonists
-Exemplars, AE’s and Info
- Clonidine
- Guanfacine
- Can cause Drowsiness
- Used with ADHD
- AVOID abrupt withdrawal and TAPER to D/C
Centrally-acting Agents: Alpha Agonists
-Methyldopa
- Used during PREGNANCY
- Can cause:
- Sedation, Orthostatic hypotension, and bradycardia
Monitor:
- BP, HR
- CBC; hemolytic anemia
- LFT’s; check more frequently first 6-12 weeks and if fever. Occurs
- Contraindicated w/ hepatic disease
Mono-therapy for HTN
-When is it Appropriate?
- For those with BP <20/10 mmHg above goal**
HTN
-Common Meds to start treatment?
- ACEi
- ARB
- Long Acting Di-hydropyridine CCB (Amlodipine/Norvasc)
Higher Dose Antihypertensive??
-Is it a good idea?
- Increasing HTN med to higher doses is shown to:
- INCREASE Adverse effects w/out significant clinical value to HTN. - Consider titrating dose up slowly or COMBINATION therapy
HTN Sequential Therapy on Mono-therapy
If patient has not responded to initial mono-therapy
-Try one drug, step it up, then try a new medication w/out combination
When to use Combination Therapy?
- Combination therapy for untreated HTN >20/10 mmHg.
HTN Combination Therapy
-Best Combo?
- Long acting ACEi or ARB
PLUS - Long acting di-hydropyridine CCB (Amlodipine) (ACCOMPLISH TRIAL showed these results)
