Therapeutics - Hypertension Part 2 Flashcards
name 2 mineralocorticoid receptor antagonists
eplerenone
spironolactone
mineralocorticosteroid receptor antagonists are the preferred agents in what 2 scenarios
primary aldosteronism and resistant hypertension
is spironolactone considered a diuretic
yes
dosage range eplerenone
dosage range spironolactone
how many x a day?
50-100mg eplerenone
25-100mg spironolactone
eplerenon - 1-2x a day
spironolactone - 1x day
____ is associated with greater risk of gynecomastia and impotence compared to _____
(spironolactone or eplerenone)
what can be done to avoid?
spironolactone is greater risk
use low dose
3 scenarios in which spironolactone/eplerenone should be avoided
-with potassium supplements
-other potassium sparing diuretics
-significant renal dysfunction
too much potassium is a concern if spironlaconte/eplerenone is given with what other classes of BP medication
ACE inhibitors or ARBS
off label, spironolactone/eplerenone can sometimes be used for ____
albuminuria
also used in stage IV heart failure
are beta blockers 1st line for HTN?
NO
unless the patient has ischemic heart disease or heart failure
or in pts with bronchospastic airway disease that needs a beta blocker
which 2 specific beta blockers are preferred in patients with HFrEF?
(heart failure where left ventricle cant pump enough blood to body)
bisoprolol and metoprolol succinate
true or false
beta blockers should not be stopped abruptly
TRUE
which beta blockers induces nitric oxide and thus induces vasodilation
nebivolol
which type of beta blockers are avoided in patients with reactive airway diseases?
name 2 specific ones
noncardioselective ones
propanolol, nadolol
which type of beta blockers are avoided, especially in patients with ischemic heart disease or heart failure
ones with intrinsic sympathomimetic activity
name 2 beta blockers which have combined alpha and beta receptor action and thus have dual mechanism
which is preferred in pts with HFrEF?
carvedilol and labetolol
carvediolol
true or false
BBs are a good choice to start in a hypertensive patient with asthma
what about:
ischemic heart disease?
arrythmia?
tachycardia?
HFrEF
diabetes
migraines
NO
ischemic heart disease - yes
arryhtmia - yes
tachycardia - yes
HFrEF - yes
diabetes - no
migraines - yes. propranolol can be used for migraine prevention
why are beta blockers generally avoided in diabetic patients
bc they can mask hypoglycemia
pt has hypertension + migraines?
which class of drug is recommended
b blockers
role of loop diuretics in hypertension
normally not used for hypertension, but are preferred in patients who have edema related to heart failure
ALSO, preferred over thiazides in pts with mod-severe kidney disease (less than 30mL/min)
name 3 loop diuretics
frequency of each?
furosemide twice a day
torsemide once a day
bumetanide twice a day
usual dose/day furosemide
20-80mg
usual dose/day torsemide
5-10mg/day
usual dose bumetanide
0.5-4mg/day
at HIGH DOSES, what are 2 toxicities of loop diuretics
ototoxicity
renal toxicity
TRUE OR FALSE
loop diuretics can increase all electrolytes and we need to monitor this
FALSE
depletes all electrolytes and we need to monitor
name 2 potassium sparing diuretics
amiloride
triamterene
when using potassium sparing diuretics, pt should be monitored for ___ kalemia
hyper
role of amiloride and triamterene in HTN
not used as monotherapy - minimally effective
combo with a thiazide – can be used in patients with hypokalemia when on thiazide monotherapy
potassium sparing diuretics like triamterene and amiloride should be avoided in patients with significant ____
chronic kidney disease
name 3 alpha1 blockers
doxasozin
prazosin
terazosin
alpha 1 blockers are more commonly used for ____ than for hypertension
why?
BPH
bc orthostatic hypotension in older adults and cause vivid dreams, and they help in BPH by increasing urine flow
_____ is used for nightmares related to PTSD
prazosin (a1 blocker)
a1 blockers may be considered as ___ line agents in patients with concomitant BPH
2nd
name 3 alpha 2 agonists
clonidine (oral/patch)
methyldopa
guanfaci
role of a2 agonists in hypertension
LAST LINE bc of CNS adverse effects (esp older ppl)
____should NOT be abruptly discontinued
why?
clonidine
may cause hypertensive crisis. taper off to avoid rebound HTN
clonidine may have some street value
what does this mean
decreases opioid withdrawal symptoms and has psychoactive effect (high)
2 alternate uses for clonidine
ADHD
2nd line as smoking cessation
name 2 direct vasodilators
minoxidil
hydralazine
role in therapy for direct vasodialtors
not commonly used for HTN
associated with sodium and water retention, as well as reflex tachycardia
they’re used with a loop diuretic and a beta clocker
which direct vasodilator is associated with lupus-like syndrome at higher doses and is thus avoided
hydralazine
minoxidil is associated with ___ and requires a ____
it can induce ___
hirsutisn, loop diuretic
can induce pericardial effusion
3 classes of HTN meds that should definitely be avoided in pregnancy
ACEi’s
ARBs
aldosterone antagonists (spironolactone, eplerenone)
3 preferred htn meds in pregnancy
labetolol
long-acting nifedipine
can use methyldopa, but there’s more AE so not rly used
define resistant HTN
taking 3 meds with different MOA but still no BP control
OR
achieve BP control but needs 4 meds or more
3 meds with the BEST evidence for treating resistant HTN
spironolactone!
hydralazine or minoxidil
how can the dosing regimen be altered to potentially help someone with resistant HTN
take some meds in morning and some at night to get full 24 hr coverage
diuretics are preferred to give what time of day
morning, not night
so not etting up to pee all the time
calcium channel blockers are preferred to give what time of day
night bc some ppl get headache from it
2 scenarios in which a HTN resistant patient should be referred to a specialist
if there is a known or suspected secondary cause
-if the BP is still uncontrolled after 6 months of treatment
compare and contrast a hypertensive urgency vs emergency
-BP
-symptoms
-treatment
both have same BP : over 180/120
however, in urgency, there is no symptoms or complaints
in emergency, there is evidence of new or worsening organ damage — dizzy, SOB, chest pain
treatment for urgency: intensify oral antihypertensive in outpatient setting
treatment for emergency: go to hospital for IV antihypertensives
(even if just 1 symptom) bc increased risk of heart attack, stroke
symptoms aortic dissection in hypertensive emergency
back pain
possible stroke symptoms
headache, confusion, dizziness
