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Renal > Pharmacological Management of Hypertension > Flashcards

Pharmacological Management of Hypertension Flashcards

1
Q

What is the difference between primary and secondary hypertension?

A
  • Primary hypertension
    • ​Idiopathic; unknown origin; >90% of cases.
  • Secondary hypertension
    • ​Known cause; <10% of cases.
    • Examples: renal disease, phaeochromocytoma, diabetes, Cushing’s, some drugs.
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2
Q

Differentiate between ‘low’ BP, normal BP, stage 1 and stage 2 hypertension.

A
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3
Q

What are the chances of harm due to hypertension?

A
  • Depends on:
    • How high the BP is
    • How long the person has had high BP
    • Whether any relevant concurrent health problems (such as high cholesterol or diabetes)
    • Concordance with medication / lifestyle changes
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4
Q

What is hypertension a major risk factor for?

A
  • Stroke
  • MI
  • Heart failure
  • CKD
  • Cognitive decline
  • Premature death
  • Untreated hypertension can cause cascular and renal damage leading to a treatment-resistance state.
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5
Q

What are the goals of hypertension treatment?

A
  • Reduce arterial BP to recommended targets.
  • Reduce risk of end organ damage (CV, renal, cerebrovascular).
  • Reduce risk of mortality due to CV disease.
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6
Q

Describe the care pathway for hypertension.

A
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7
Q

What are the indications to prescribe for management of hypertension?

A
  • Patients of any age with stage 2 or 3 hypertension.
  • Patients with stage 1 hypertension who have one or more of the following:
    • Target organ damage
    • Established CV disease (CHD, CVA)
    • Renal disease
    • Diabetes
    • 10-year CV risk equivalent to 20% or greater
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8
Q

What are the risk score calculators for estimating CV risk?

A
  • ASSIGN
  • Qrisk
  • JBS3
  • Based on:
    • BP
    • Age
    • Weight/height
    • Gender
    • Smoking
    • Cholestrol
    • Ethnicity
    • Social class
    • Family history
    • Diabetes, rheumatoid arthritis, renal function
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9
Q

What are the BP treatment targets?

A
  • Standard patients
    • <140/90mmHg
  • Over 80 years of age
    • <150/90mmHg
    • More important than controlling BP is preventing falls. Do not drop BP too fast or too low.
  • Cardiac / renal disease or diabetes
    • <130/80mmHg
  • BUT, make it patient centres:
    • Individualised targets based on appropriateness, tolerability and frailty.
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10
Q

Before prescribing anti-hypertensive medication, you must review the patient’s drugs.

Which drugs cause a possible increase in BP?

A
  • NSAIDs (e.g. ibuprofen, diclofenac)
  • Oral steroids (e.g. Prednisolone)
  • Venlafaxine (anti-depressant)
  • Oral sympathomimetic decongestants (e.g. Pseudoephedrine - “Sudafed”)
  • Soluble or dispersible drugs - contains SALT
  • Illicit drug use.
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11
Q

What are the factors which regulate arterial BP?

A
  • Cardiac output (CO) - HR, SV
  • Total peripheral resistance (TPR) - or systemic vascular resistance.
  • TPR x CO = MAP
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12
Q

Give a summary of the stepwise anti-hypertensive drug treatment.

A
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13
Q

What are the major classes of anti-hypertensive drugs?

A
  • Renin-Angiotensin system inhibitors
  • ​Calcium channel blockers
  • Diuretics
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14
Q

Give examples of the Renin-Angiotensin system inhibitors.

A
  • ​Angiotensin converting enzyme inhibitors (ACE inhibitors)
    • Ramipril, lisinopril, captopril
  • Angiotensin AT1 receptor antagonists (ARBs)
    • Losartan, candesartan, irbesartan
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15
Q

Give examples of calcium channel blockers.

A
  • Amlodipine
  • Felodipine
  • Lercanidipine
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16
Q

Give examples of the diuretics used in management of hypertension.

A
  • Thiazide-like diuretics - often essential at step 2 or 3, but not effective in moderate-severe renal impairment.
    • Indapamide, bendroflumethiazide
  • High dose loop diuretics (e.g. Furosemide) may be used for raised BP in renal failure.
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17
Q

What are the additional treatments for resistant hypertension?

A
  • Sympathetic nervous system antagonists
    • β-blockers
      • E.g. atenolol
    • α1 adrenoceptor blockers
      • E.g. doxazosin
  • Kidney function modifiers
    • Potassium sparing diuretics and aldosterone antagonists
      • E.g. amiloride, spironolactone
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18
Q

Describe the parts of the pathway which ACE-Inhibitors and ARBs act upon to produce their anti-hypertensive effects.

A
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19
Q

What are the contraindications for prescribing ACE-I or ARBs?

A
  • Allergy, hypersensitivity.
  • History of angioneurotic oedema (hereditary, idiopathic or due to previous angioedema with ACE-I or ARBs).
  • Significant bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney.
  • Pregnancy.
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20
Q

What are the common side effects of ACE Inhibitors?

A
  • Persistent dry cough (15%) which is untreatable (patients need to switch to ARB); dizziness; tiredness; headaches.
  • Slight increased risk of angioedema in African/Carribean ethnicity.
  • Risk of hyperkalaemia (care with drug interactions).
  • Renal impairment.
21
Q

What are the common side-effects of ARBs?

A
  • Dizziess; headaches; back / leg pain.
  • Risk of hyperkalaemia, renal impairment.
22
Q

Describe the mechanism of action of calcium channel blockers.

A
  • Block entry of calcium through slow channels in cardiac and smooth muscle.
  • Reduce cardiac output (class 4 anti-arrhythmics - verapamil, diltiazem).
  • Peripheral vasodilation, reduced TPR.
23
Q

Which kind of calcium channel blockers should be used as anti-hypertensives and why?

A
  • In hypertension, use dihydropyridine-like CCBs:
    • E.g. amlodipine, felodipine, lercanidipine.
  • Used because they have less effect on cardiac muscle cells, greater impact on vascular smooth muscle, reduces PR.
24
Q

What are the contraindications of dihydropyridine-like calcium channel blockers?

A
  • Uncontrolled heart failure
  • Cardiogenic shock (MI) (recent)
  • Significant aortic stenosis
  • Unstable angina
  • Pregnancy (but consider risk / benefit)
25
Q

What are the common side-effects of dihydropyridine-like calcium channel blockers?

A
  • Flushes
  • Headaches
  • Ankle oedema
  • Dizziness
26
Q

Which classes of drugs are kidney function modifiers?

Where in the kidney do they act?

A
  • Thiazide-like diuretics
  • Aldosterone antagonists
27
Q

Give examples of thiazide-like diuretics.

A
  • Indapamide
  • Bendroflumethiazide
28
Q

Give an example of an aldosterone antagonist.

A
  • Spironolactone
29
Q

What is the mechanism of action of thiazide diuretics?

A
  • Inhibits the NaCl co-transporter in the distal tubule
    • so less NaCl is reabsorbed
    • so causing moderate diuresis, reducing oedema and BP.
  • Direct relaxant effect on vascular smooth muscle (reduces BP).
30
Q

What are the indications for prescribing thiazide?

A
  • Hypertension (not if also have moderate-severe renal impairment).
  • Mild heart failure.
  • Severe resistant oedema (plus loop diuretic).
  • Nephrogenic diabetes insipidus.
31
Q

Give examples of the contraindications for prescribing thiazides.

A
  • Hypercalcaemia
  • Hyponatraemia
  • Hypokalaemia
  • Symptomatic hyperuricaemia
  • Addison’s disease
32
Q

What are the common side-effects of thiazides?

A
  • Low K, Na, Mg
  • Promotion of calcium retention / hypocalciuria
  • Metabolic alkalosis
  • Gout
  • Erectile dysfunction
  • Hyperglycaemia, hyperlipidaemia
33
Q

What are the indications for aldosterone antagonists?

A
  • Hypertension
  • Oedema (heart, liver, nephrotic syndrome)
  • Conn’s syndrome (primary hyperaldosteronism)
34
Q

From which class of drugs are aldosterone antagonists?

A

Mineralocorticoid receptor antagonists (MRAs).

35
Q

What are the contraindications for prescribing mineralocorticoid receptor antagonists?

A
  • Addison’s disease
  • Anuria / kidney failure +++
  • Hyperkalaemia
36
Q

What are the side-effects of mineralocorticoid receptor antagonists?

A
  • Hypotension
  • Renal impairment
  • High potassium (care if renal impairment!)
  • Hyponatraemia
  • GI upset
  • Metabolic acidosis
  • Gynaecomastia with spironolactone
37
Q

What is amiloride?

Describe its mechanism of action.

A
  • Potassium-sparing weak diuretic.
  • Acts by directly blocking epithelial sodium channels in the collecting tubule so less sodium is reabsorbed, causing diuresis.
  • Usually synergistically combined with thiazide or loop diuretics.
38
Q

What are the indications for amiloride?

A
  • Hypertension
  • Oedema including ascites
39
Q

What are the contraindications for amiloride?

A
  • Addison’s disease
  • Anuria
  • Hyperkalaemia
40
Q

What are the side-effects of amiloride?

A
  • High potassium (care if renal impairment)
  • GI upset
  • Metabolic acidosis
  • Renal impairment
41
Q

What are β-blockers?

Give examples.

A
  • Sympathetic nervous system antagonist
  • Atenolol, Bisoprolol, Carvedilol
    • β1 receptor blockers (cardioselective)
    • Act centrally, reducing sympathetic activity, reduce CO, and also reduces renin release.
    • No longer first choice
    • Less effective at reducing cardiac events and stroke than ACE-I / ARB, CCB and thiazides.
42
Q

What are the contraindications for β-blockers?

A
  • Asthma
  • Cardiogenic shock / uncompensated heart failure
  • Hypotension
  • Marked bradycardia
  • Severe peripheral arterial disease
43
Q

What are the β1-blocker side effects?

A
  • Fatigue
  • Cold extremities
  • Peripheral vascular disease
  • Bradycardia
  • Bronchospasm
  • GI upset
  • Erectile dysfunction
  • Heart failure
  • Sleep disorders
44
Q

Describe the mechanism of action of α1 antagonists.

Give an example.

A
  • Example: doxazosin
  • Sympathetic NS antagonist, blocking alpha 1 receptors.
  • Block vasoconstriction, resulting in vasodilation.
45
Q

What are the side-effects of α1 antagonists?

A
  • Postural hypotension
  • Dizziness
  • Lethargy
  • GI upset
  • Headache
  • Peripheral oedema
46
Q

What are the contraindications for α1​ antagonists?

A
  • History of micturition syncope (in patients with benign prostatic hypertrophy)
47
Q

Summarise antihypertensive drug treatment.

48
Q

What are the pros of multi-drug treatment of hypertension?

A
  • Reduced mortality / morbidity.
  • Each drug class working at different sites on the body - can achieve BP targets more quickly.
  • Reduces dose burden of individual drugs, thereby minimising side-effects.
49
Q

What are the cons of multi-drug treatment of hypertension?

A
  • Concordance a problem:
    • “I felt fine before I started these drugs!”
    • “I keep forgetting to take all these drugs!”
    • Side-effects may be more frequent
    • Increased drug costs to the NHS

Renal (10 decks)

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