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Therapeutics II > Therapeutics of HTN > Flashcards

Therapeutics of HTN Flashcards

1
Q

Contraindications with ARBs

A
  • history of angioedema on an ARB
  • concomitant use of aliskiren in patients w/ DM
  • pregnancy/breastfeeding
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2
Q

Why to avoid _________ dihydropyridines?

A

short-acting

can cause severe tachycardia

ex: IR nifedipine, nicardipine

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3
Q

aliskiren is _____ first line for HTN

A

NOT

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4
Q

When to avoid nonselective beta blockers

A

in pts with bronchospastic airway disease (ask pt if they have a history of asthma or COPD)

these meds can be used for tremor or migraine because non selective

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5
Q

monitoring for BBs

A

heart rate

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6
Q

Contraindications of aldosterone antagonists

A

E : impaired renal fxn or T2DM or proteinuria

Both (E, S) : concomitant use of K sparing diuretics

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7
Q

What was the PATHWAY-2 trial?

A
  • small group maximized on ACEi or ARB, CCB and thiazide for at least 3 months
  • results: spironolactone > placebo/doxazosin/bisoprolol as add-on therapy in resistant HTN
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8
Q

What alpha 2 agonist is preferred in pregnancy?

A

methyldopa

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9
Q

Dosing frequency of loop diuretics

A

F : QD or BID
T : QD
B : QD or BID (this has the lower dose)

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10
Q

examples of central alpha 2 agonists

A
  • clonidine
  • methyldopa
  • guanfacine
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11
Q

Frequency of dosing for aliskiren

A

QD

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12
Q

When make the switch from spironolactone to eplerenone?

A

When pt develops gynecomastia (occurs 10% of the time)

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13
Q

dosage forms of central alpha 2 agonists

A

clonidine: PO (BID - TID) and transdermal weekly patch (lower risk of rebound HTN and improved adherence w/ patch)

methyldopa PO

guanfacine PO

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14
Q

Diuretic monitoring in a basal metabolic panel

A
  • confirm baseline, check in 1 - 2 wks, 6 - 12 mon for electrolytes and renal fxn
  • only check loop diuretics and aldosterone antagonists 3 - 4 wks after initiation
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15
Q

What do nondihydropyridines do?

A

slows AV node conduction and decreases heart rate (negative ionotropic effect)

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16
Q

HTN goals of tx

A
  • decrease morbidity/mortality
  • reach BP targets
  • select agents with proven CV benefit
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17
Q

clonidine clinical pearls

A
  • titrating off (slow wean-half dose every 2 - 3 days); concomitant use with beta blocker
  • oral to transdermal patch (overlap oral regimen for 3 - 4 days)
  • patch to oral (consider starting oral no sooner than 8 hours after patch removal)
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18
Q

Adverse effects of ARBs

A
  • angioedema
  • hyperkalemia
  • acute renal failure w/ severe bilateral renal artery stenosis
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19
Q

DASH diet (reduce BP 11 mmHg)

A
  • vegetables and fruits
  • whole grains
  • fat-free or low-fat dairy products
  • fish, poultry, beans
  • nuts and vegetable oils
  • foods rich in K, Ca, Mg, fiber, PRT and lower in Na

LIMIT FOODS THAT ARE:

  • high in saturated fats
  • sugar-sweetened beverages and sweets
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20
Q

What if pt not at goal

A
  • consider QHS dosing of one of the antihypertensives (could be for ACEi, ARBs and CCB - NEVER for diuretics)
  • assess adherence (QD vs multiple dosing; combination products)
  • educate on diet, exercise and smoking cessation
  • rule out white coat HTN
  • discontinue interfering substances
  • pt may have resistant HTN
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21
Q

ARBs are a good option for ______

A

PM dosing to ensure nocturnal “BP dipping”

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22
Q

contraindications for beta blockers

A
  • second or third degree heart block
  • decompensated heart failure
  • post-MI (ISA BBs only)
  • severe bradycardia
  • sick sinus syndrome
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23
Q

For loop diuretics, is it helpful to switch to another loop diuretic or from PO to IV?

A

YES

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24
Q

If stage 1 HTN

A
  • if ASCVD >/= 10% or a specific comorbidity:
  • Yes: non pharm and med –> reassess in a month
  • No: non pharm –> reassess in 3 - 6 months
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25
Q

Normal HTN

A

S: < 120 AND
D: < 80

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26
Q

Cons of HBPM and ABPM

A
  • user error
  • equipment cost
  • insurance reimbursement
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27
Q

isolated systolic HTN

A

systolic BP values are elevated and diastolic BP values are not

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28
Q

examples of direct arterial vasodilators

A
  • hydralazine

- minoxidil

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29
Q

monitoring for ACEi/ARB

A

BUN/Scr, K

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30
Q

Substances that increase BP

A
  • illicit drugs
  • caffeine
  • nicotine
  • decongestants
  • amphetamines
  • antidepressants
  • atypical antipsychotics
  • immunosuppressants
  • oral contraceptives
  • NSAIDs
  • Systemic steroids
  • oncology agents
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31
Q

If elevated BP, 120 - 129/< 80

A
  • non pharmacological treatment

- reassess in 3 - 6 months

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32
Q

Potassium-sparing diuretics have ______ BP effects

A

minimal

used in combo with thiazide to minimize hypokalemia

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33
Q

Patient specific factor: Cerebrovascular Disease

Secondary stroke prevention

A
  • ACEi/ARB
  • Thiazide diuretic*
  • Combination of the above
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34
Q

Patient Specific factor: Pregnancy

Preferred and contraindicated

A

Preferred:

  • methyldopa
  • nifedipine
  • labetalol

Contraindicated (meds that impact RAAS system):

  • ACEi
  • ARB
  • Direct renin inhibitor
  • hesitate to use thiazide diuretics
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35
Q

Adverse effects of aliskiren

A
  • Extensive
  • diarrhea
  • musculoskeletal effects
  • dizziness
  • HA
  • hyperkalemia
  • renal insufficiency/ARF
  • orthostatic hypotension
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36
Q

What do ARBs do?

A

Blocks effects of angiotensin II by binding to target receptors

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37
Q

beta blockers can mask signs of __________

A

hypoglycemia

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38
Q

Adverse effects of loop diuretics

A
  • hypokalemia
  • hypomagnesemia
  • hypocalcemia
  • hyperuricemia
  • ototoxicity
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39
Q

resistant HTN is a _______ meaning must ________

A

disease of exclusion ; rule out secondary causes of HTN, nonadherence, whitecoat HTN, etc

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40
Q

BP goals

A

ACC/AHA: < 130/80 (may consider < 140/90 in elderly frail pts)

ADA: < 140/90 (goal of < 130/80 for CVD or ASCVD > 15%

KDIGE: < 140/90 w/out albuminuria; < 130/80 w/ albuminuria

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41
Q

HTN Stage 2

A

S: >/= 140 OR
D: >/= 90

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42
Q

ACC/AHA recommendation for choice of initial medication

A

FIRST-line agents should include thiazide diuretics*, CCBs and ACE inhibitors or ARBs

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43
Q

What to remember with beta blockers?

A

avoid abrupt cessation

titrate!

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44
Q

When is spironolactone preferred?

A

With resistant HTN

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45
Q

When to dose K sparing diuretics?

A

-morning to avoid nocturnal diuresis

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46
Q

Loop diuretics are preferred in _________

A

heart failure for symptom management

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47
Q

What does ACEi do?

A

Prevents conversion of angiotensin I to angiotensin II

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48
Q

Pros of HBPM and ABPM

A
  • confirm diagnosis
  • aide in medication titration
  • identify white coat and masked HTN
  • Better predictor of long-term cardiovascular outcomes
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49
Q

Mixed alpha/beta blockers - examples and when to use

A
  • carvedilol (BID), labetalol (BID)

- great for BP because block alpha receptors

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50
Q

Patient specific factor: Ethnicity and Race

In black adults with HTN but without ___ and ___, including those with DM, initial antihypertensive tx should include a _______ or _______

A

HF ; CKD ; thiazide diuretic ; CCB

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51
Q

ALLHAT Trial

A
  • pts with HTN and 1 additional risk factor
  • pts randomized to chlorthalidone, lisinopril-based therapy, amlodipine, doxazosin
  • Results: Chlorthalidone > amlodipine and lisinopril based therapy in preventing stroke, heart attacks and heart failure
  • Doxazosin stopped early due to increased risk of heart failure

LEARNED THAT thiazide diuretics should be first line therapy

If can’t take diuretic, consider a CCB or ACE-I

MOST pts with high BP need more than one drug

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52
Q

CCB clinical pearls

A
  • no routine lab monitoring
  • check for drug interactions
  • dihydropyridine CCBs are first line for HTN
  • peripheral edema is dose-dependent
  • extended release formulations are preferred
  • nondihydropyridine CCB formulation are not interchangeable
  • if a CCB is needed in the setting of heart failure, choose amlodipine*
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53
Q

Chlorthalidone is ____ than HCTZ. But HCTZ is _____ and _____

A

1 - 2 x more potent ; more common ; cheaper

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54
Q

Intrinsic sympathomimetic activity (ISA) beta blocker examples and facts

A
  • acebutolol (BID), penbutolol (QD), pindolol (BID)
  • not common, avoid in heart failure and IHD
  • used in pts who need beta blocker but heart rate too low (blocks heart rate from going up)
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55
Q

____ is the most significant risk factor for cardiovascular disease

A

HTN

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56
Q

Patient specific factor: Heart Failure (Reduced Ejection Fraction)

A

Reduced ejection fraction: follow most recent failure guidelines
-avoid non-dihydropyridine CCBs

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57
Q

Examples of aldosterone antagonists

A
  • spironolactone

- eplerenone

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58
Q

Adverse effects of dihydropyridine CCBs

A
  • reflex tachycardia
  • flushing
  • dizziness
  • HA
  • peripheral edema (dose-related)
  • gingival hyperplasia
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59
Q

ACCORD trial

A

-pts WITH diabetes age 40 - 79 w/ CVD or multiple CVD risk factors

  • -BP goals:
  • **Intensive group: < 120 (achieved 119.3)
  • **standard group: < 130 - 140 (achieved 133.5)
  • reduced risk of stroke 44%
  • increased risk of adverse events
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60
Q

Examples of non selective beta blockers

A
  • nadalol
  • propanolol IR
  • propanolol LA
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61
Q

How do beta blockers work?

A

-decrease heart rate + decrease force of contraction –> decrease in CO

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62
Q

Examples of loop diuretics

A
  • furosemide
  • bumetanide
  • torsemide
  • ethacrynic acid

BTFE!

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63
Q

Drug interactions of dihydropyridines

A
  • grapefruit juice
  • CYP3A4 enzyme inducer/inhibitor

*pay attention to drug interactions with statins

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64
Q

Dosing frequency of nonselective beta blockers

A

nadalol and propanolol LA are QD but propranolol IR is BID

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65
Q

For loop diuretics, may need ______ doses with _________ or ____________

A

higher dose ; severely reduced renal fxn ; fluid overload

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66
Q

When will thiazide diuretic not work?

A

When CrCl < 30 ml/min

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67
Q

Dosing frequency of cardioselective beta blockers

A

all but short-acting metoprolol tartrate (BID) is QD

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68
Q

ACEi/ARB Monitoring

A

Monitor K+ and renal fxn at baseline, 1 - 2 wks after initiation (check BMP within 1 week for elderly), 3 - 4 wks after initiation (only if elevated Scr), every 6 - 12 months

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69
Q

Nondihydropyridines CCBs are _____ first line tx for HTN

A

NOT

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70
Q

HTN Pharmacologic treatment options

A
  • ACE inhibitors
  • ARBS
  • CCB
  • Direct renin inhibitors
  • Beta blockers
  • Diuretics
  • alpha 1 and 2 blockers
  • vasodilators
  • sympatholytic agents
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71
Q

ACEi is a ________ for HTN

A

first line

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72
Q

Loop diuretics are ______ first line for HTN

A

NOT

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73
Q

Most studied thiazide

A

chlorthalidone

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74
Q

orthostatic HTN

A

a systolic BP decrease of greater than or equal to 20 mmHg, a diastolic BP decrease of greater than or equal to 10 mmHg within 3 minutes of positional change, and/or increase in heart rate greater than 20 bpm

75
Q

direct arterial vasodilators are ______therapy for HTN

A

last line

76
Q

Pt populations with additional benefit from beta blockers

A
  • tachyarrhythmias
  • tremors
  • migraines
  • thyrotoxicosis
77
Q

What do renin inhibitors do?

A

Blocks conversion of angiotensinogen to angiotensin I

78
Q

When do not initiate aldosterone antagonist?

A

With potassium > 5mEq/L. ***consider holding dose if K+ > 5.5 mEq/L or Scr increase > 25%

79
Q

Modifiable HTN risk factors

A
  • high Na intake
  • obesity
  • low K intake
  • excess alcohol intake
80
Q

Benefit of controlling HTN is worth the risk of ______

A

increasing blood sugar

81
Q

Angiotensin Inhibitor Clinical Pearls

A
  • discuss contraceptive methods with women of childbearing age
  • do not combine drug classes
  • assess pt’s risk for hyperkalemia
  • educate pt on dietary sources of K
  • ACEi/ARBs often preferred over other first line agents in the presence of other compelling indications
82
Q

Warnings with dihydropyridine CCBs

A

increased risk of angina/MI in pts with obstructive coronary disease due to reflex tachycardia

83
Q

risk factors for resistant HTN

A
  • older age (blood vessels are more stiff)
  • obesity
  • CKD
  • diabetes
  • Black
84
Q

Examples of nondihydropyridines are

A
  • diltiazem ER

- verapamil ER

85
Q

Use aliskiren when pregnant?

A

No

86
Q

Pts with ______ (4) benefit from the use of ACEi

A
  • diabetes w/ proteinuria
  • Heart failure
  • Post MI
  • CKD
87
Q

use beta blockers with caution in pts with

A
  • peripheral artery disease (carvedilol preferred)

- reactive airway disease (use selective BBs)

88
Q

Frequency of dosing for aldosterone antagonists

A

S : QD or BID

E : QD or BID

89
Q

Diuretic clinical pearls

A
  • DON’T GIVE AT BEDTIME
  • Thiazides are first line for most HTN pts
  • Spironolactone is first line for pts with resistant HTN
  • Don’t use K+ sparing diuretics as monotherapy for HTN
  • Pay attention to pt allergies (sulfa)
  • Check CrCl when choosing diuretic class
  • Important to monitor K (and other electrolytes)
90
Q

With nondihydropyridines, what formulation are preferred for HTN?

A

extended-release

91
Q

Long term consequences of HTN

A
  • left ventricular hypertrophy
  • angina or MI
  • coronary revascularization
  • heart failure
  • stroke or TIA
  • CKD
  • peripheral vascular disease
  • retinopathy
92
Q

How does aliskiren impact bradykinin?

A

It doesn’t! Therefore, less cough

93
Q

Adverse effects of beta blockers

A
  • bronchospasms
  • bradycardia
  • fatigue
  • exercise intolerance
  • depression
94
Q

Direct renin inhibitor

A

aliskiren

95
Q

Why are dihydropyridine more potent than nondihydropyridines?

A
  • vasodilation –> baroreceptor-mediated tachycardia

- no effect on atrioventricular node conduction

96
Q

SPRINT trial

A

-pts without diabetes or prior stroke

  • BP goals:
  • **Intensive group: < 120 (achieved 121.4)
  • **standard group: < 140 (achieved 136.2)
  • reduced risk of death 27%
  • average of 2.8 medications used
  • increased risk of electrolyte abnormalities, hypotension and AKI
97
Q

Adverse effects of thiazide diuretics

A
  • hypokalemia
  • hypomagnesemia
  • hypercalcemia
  • hyperuricemia
  • hyperglycemia
  • hyperlipidemia
  • sexual dysfunction
98
Q

Patient specific factor: Heart Failure

Preserved ejection fraction: For fluid overload

A

Diuretic

99
Q

Subclasses of CCBs

A
  • dihydropyridines (more vasodilation)
  • nondihydropyridines (more inotropic effects)
  • similar effect on BP
100
Q

resistant HTN

A

fail to attain goal BP while adherent to a regimen that includes at least 3 agents at maximum dose (including a diuretic or when 4 or more agents are needed)

101
Q

Pt populations that would receive additional benefit from dihydropyridine

A
  • reynaud syndrome (cold extremities)

- elderly pts w/ isolated systolic HTN

102
Q

HTN Stage 1

A

S: 130 - 139 OR
D: 80 - 89

103
Q

Essential HTN pathophysiology

A
  • humoral abnormalities
  • neuronal mechanisms
  • vascular endothelial mechanisms
  • peripheral autoregulation defects
  • electrolyte disturbances
104
Q

ACEi/ARB monitoring: Consider ________ if ________

A

holding or reducing dose if K+ > 5.5 mEq/L or Scr increase > 30%

Counsel on ways to decrease K+

105
Q

Patient specific factor: Heart Failure

Preserved ejection fraction: For elevated heart rate

A

Beta blocker

106
Q

minoxidil is __________ than hydralazine

A

more potent

107
Q

monitoring for aldosterone antagonists

A

BUN/Scr, K

108
Q

ARBs impact HTN by ________

A
  • vasodilation
  • reduced PVR
  • Increased diuresis
109
Q

it should be noted that with alpha 1 blockers and HTN…

A

THEY SHOULD NEVER BE USED FIRST LINE FOR HTN

110
Q

monitoring for CCBs

A

heart rate (non-dihydropyridine)

111
Q

alpha 2 agonists are ______ due to _______

A

last line ; adverse effects

112
Q

Thiazide diuretics are more effective than ______ with ______

A

loop diuretics ; CrCl > 30ml/min

113
Q

Management of resistant HTN

A

Step 1: maximize lifestyle interventions, optimize 3 drug regimen (ACEi or ARB, CCB and diuretic)

Step 2: substitute optimized thiazide-like diuretic (chlorthalidone, indapamide)

Step 3: add mineralocorticoid receptor antagonist (spironolactone, eplerenone)

Step 4: add BB if heart rate > 70 bpm, consider central alpha 2 agonist (clonidine patch or guanfacine QHS) if BB contraindicated and/or heart rate < 70 bpm

Step 5: add hydralazine

Step 6: substitute minoxidil for hydralazine

114
Q

Drug interactions with aldosterone antagonists

A
  • ACEi
  • ARBs
  • Renin inhibitors
  • NSAIDs (increase risk of hyperkalemia)
115
Q

for direct arterial vasodilators, exercise caution when pts have (5)

A
  • CVA
  • renal impairment
  • CAD
  • Liver disease
  • SLE
116
Q

When to dose loop diuretics?

A

Morning or afternoon to avoid nocturnal diuresis

117
Q

Frequency of ACEi dosing

A

Everything QD except captopril is BID

118
Q

If normal BP, how to address

A
  • promote healthy lifestyle

- reassess in 1 year

119
Q

Patient Specific factor: Diabetes

A

All first-line classes are useful and effective

But in the presence of albuminuria: ACEi or ARB

120
Q

Adverse effects of ACEi

A
  • angioedema
  • cough (excess of bradykinin)
  • hyperkalemia
  • acute renal failure w/ severe bilateral renal artery stenosis
121
Q

ARBs are considered _____ for HTN but _____

A

first line ; also kind of a back up

122
Q

Can use ARBs in pts with ________

A

history of cough with ACEi

123
Q

HTN pts at GOAL should have follow up every ______

A

3 - 6 months

124
Q

adverse effects of alpha 2 agonists

A
  • CNS depression
  • dizziness
  • fatigue
  • anticholinergic effects
  • bradycardia
  • reflex tachycardia
  • fluid retention

(notice both bradycardia and tachycardia)

125
Q

When de-escalating therapy…

A

identify the first and second line therapy options that have the most potential for adverse effects

example 1st line: amlodipine, chlorthalidone

example 2nd line: carvedilol, hydralazine

126
Q

Diuretics in HTN

Initial anti-hypertensive effects:
-diuresis –> ______ SV –> ______ PVR

A

reduced ; increase

127
Q

alpha 1 blockers are associated with ________ especially in the _______

A

orthostatic HTN ; elderly

128
Q

Patient specific factor: Heart Failure

Preserved ejection fraction: For elevated BP

A

ACEi/ARB

129
Q

Thiazide diuretics should be dosed ________

A

IN THE MORNING

130
Q

Nebivolol acts by ____________

A

nitric oxide induced vasodilation

131
Q

Contraindications of ACEi

A
  • history of angioedema on an ACEi
  • concomitant use of aliskiren in pts w/ DM
  • pregnancy/breastfeeding (avoid RAAS system)
132
Q

How often are thiazides commonly dosed in a day?

A

ONCE (also higher doses aren’t really a thing)

133
Q

Gender modifiable risk factor: Which gender is more likely to display HTN and at what age?

A

Age < 55: M > F

Age 55 - 64: F >/= M

Age > 64: F&raquo_space; M

134
Q

Patient populations with additional benefit from nondihydropyridines

A
  • supraventricular tachyarrhythmias (Afib)

- pts with angina who can not tolerate a beta blocker

135
Q

which direct arterial vasodilator has a black box warning and what is it?

A

minoxidil

may cause pericarditis and pericardial effusion that may progress to tamponade…may increase oxygen demand and exacerbate angina pectoris

maximum dose of a diuretic and two other antihypertensives should be used b4 this drug

136
Q

Patient specific factor: Stable Ischemic Heart Disease

A

First line:

  • beta blockers
  • ACEi/ARBs

Dihydropyridine CCBs can be used if still uncontrolled

137
Q

secondary HTN

A

elevated arterial BP due to concurrent medical conditions or medications (identifiable cause)

138
Q

Secondary HTN Risk Factors

A
  • CKD
  • renovascular disease
  • primary aldosteronism
  • obstructive sleep apnea
  • drug-induced
  • food/substances (Na, ethanol)
  • pheochromocytoma
  • cushings syndrome/chronic steroid use
  • thyroid or parathyroid disease
  • aortic coarctation
139
Q

Elevated HTN

A

S: 120 - 129 AND
D: < 80

140
Q

examples of alpha 1 blockers

A
  • doxazosin
  • prazosin
  • terazosin
141
Q

Adverse effects of aldosterone antagonists

A
  • hyperkalemia
  • hyponatremia
  • gynecomastia (spironolactone)
142
Q

Frequency of K sparing dosing

A

A : QD or BID

T : QD or BID

143
Q

BP measurement techniques

A

In office (2 readings 5 minutes apart)

Ambulatory BP monitoring (ABPM - indicated for evaluation of “white coat”, “masked” HTN and nighttime BP dipping)

Home BP monitoring (HBPM - indicated for evaluation of “white coat”, “masked” HTN, response to therapy and may improve adherence)

144
Q

Thiazide diuretics are ______ for most ____ patients

A

first line ; HTN (ALLHAT)

145
Q

For HTN patients, most are ____________

A

asymptomatic

146
Q

Patient specific factor: CKD

Post kidney transplantation

A

dihydropyridine CCBs preferred due to improved GFR and kidney survival

147
Q

definition of resistant HTN

A

failure to attain goal BP while adherent to a regimen that includes at least 3 agents at maximum dose (including a diuretic) or when 4 or more agents are needed

148
Q

Non-modifiable HTN risk factors

A
  • age
  • ethnicity
  • genetic predisposition
  • gender
149
Q

Diuretics in HTN

Chronic anti-hypertensive effects:
-SV returns to ______ –> ______ in PVR

A

normal ; decrease

150
Q

adverse effects of vasodilators

A
  • palpitations
  • tachycardia
  • chest pain
  • GI SE
  • HA
  • hematologic dyscrasias
  • hepatotoxicity
  • lupus-like syndrome/rash (hydralazine)
  • fluid retention
  • hair growth (minoxidil)
151
Q

should avoid ______ with alpha 2 agonists due to ________

A

abrupt cessation ; rebound HTN

152
Q

for direct arterial vasodilators concomitant therapy w/ ____________ and ___________ needed

A

diuretic ; beta blocker

153
Q

Adverse effects of K sparing diuretics

A
  • hyperkalemia***
  • increased uric acid (be cautious in gout pts)
  • hyperglycemia
154
Q

monitoring for other diuretics

A

BUN/Scr, electrolytes (K, Mg, Na), uric acid (thiazides)

155
Q

essential HTN

A

elevated arterial BP with an unknown etiology

156
Q

What is HTN?

A

Persistently elevated arterial BP

157
Q

Thiazide diuretics are contraindicated with _______

A
  • sulfa allergy

- anuria (aren’t producing urine)

158
Q

How do ACEi work?

A
  • effects vasodilation
  • reduced PVR
  • increased diuresis
159
Q

What diuretics are available?

A
  • thiazide
  • loop
  • aldosterone antagonists
  • k-sparing
160
Q

Contraindications of loop diuretics

A

sulfa allergy

161
Q

Name the preferred combinations

A

Preferred:

  • ACEi/CCB
  • ARB/CCB
  • ACEi/diuretic
  • ARB/diuretic

Acceptable:
-CCB/diuretic

***No ACEi/ARB combo

162
Q

Dihydropyridine CCBs

A

-first line HTN

163
Q

If stage 2 HTN

A

-non pharm + 2 meds –> reassess in a month

164
Q

Concomitant use of aliskiren with an ACEi or ARB is _________ in pts with ________

A

contraindicated ; diabetes

165
Q

alpha 1 blockers can be considered _____ for pts with concomitant _____

A

second line ; BPH

166
Q

Frequency of dosing for ARBs

A

QD (preferably at night)

167
Q

Nondihydropyridines dosing frequency

A

QD or BID

168
Q

Potassium-sparing diuretics

A
  • amiloride

- triamterene

169
Q

Examples of thiazide diuretics

A
  • Chlorthalidone
  • HCTZ
  • Indapamide
  • Metolazone
170
Q

nondihydropyridine drug interactions

A
  • concomitant use of beta blockers (increases risk of heart block)
  • grapefruit juice
  • CYP3A4 enzyme inducer/inhibitors (3A4 substrates)
171
Q

Patient specific factor: CKD

CKD stage 1 or 2 AND albuminuria

CKD stage 3 or higher (eGFR = 60)

A

ACEi (or ARB)

172
Q

What to monitor with aliskiren?

A

K, BUN, Scr

173
Q

Loop diuretics are more effective than thiazide diuretics when the CrCl is ______

A

< 30 ml/min

174
Q

Since ethacrynic acid is old, use it when ______

A

people have a sulfa allergy

175
Q

When to dose aldosterone antagonists?

A

In the morning or early afternoon to avoid nocturnal diuresis

176
Q

When to exercise caution when using a K sparing diuretic?

A

pts with diabetes and CKD (eGFR < 45 ml/min)

177
Q

Dosing frequency of dihydropyridine CCBs

A

Most QD except isradipine (BID) and nicardipine LA (BID)

pts sometimes take their dose and cut it in half to make it BID dosing

178
Q

What do CCBs do?

A

Inhibit influx of Ca across cardiac and smooth muscle cell membranes –> coronary and peripheral vasodilation

179
Q

Adverse effects of nondihydropyridines

A
  • bradycardia
  • HA
  • dizziness
  • AV node block
  • systolic heart heart failure
  • gingival hyperplasia
  • constipation (V > D)
180
Q

Beta blockers are ____ first line unless _____

A

NOT ; a compelling indication is present

compelling indication = heart failure and CAD

181
Q

direct arterial vasodilators are reserved for pts w/ ___________ or __________

A

special indications ; very difficult to control BP (i.e. severe CKD or hemodialysis)

182
Q

Contraindications of nondihydropyridine use

A
  • heart block

- left ventricular dysfunction

183
Q

When to dose ACEi?

A

PM dosing is an option to ensure “BP dipping” overnight

Therapeutics II (12 decks)

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