Therapeutics of HTN pt. 2 Flashcards
what does the ALLHAT trial stand for
Antihypertensive and lipid lowering treatment to prevent heart attack trial
what is the subject population in the ALLHAT trial
42,418 pts age >55 yo with HTN and 1 additional CV risk factor
what were the medication arms in the ALLHAT trial
Chlorthalidone, lisinopril based therapy, amlodipine, doxazosin
what was the result of the ALLHAT trial
Chlorthalidone > amlodipine and lisinopril based therapy in preventing stroke, heart attacks, and HF
*doxazosin arm stopped early due to increased risk of HF
what are the key takeaways from the ALLHAT trial
- thiazide diuretics should be first line
- for pts who cannot take a diuretic, consider prescribing a CCB or ACEi
- most pts with high BP need more than one drug
what are the preferred combination therapies
ACEi/CCB, ARB/CCB, ACEi/diuretic, ARB/diuretic
what is acceptable combination therapy
CCB/diuretic
first line for HTN with stable ischemic heart disease
1.Beta blockers - reduce CV events and anginal Sx
2. ACEi/ARBs - reduce MI, stroke, CVD
3. Dihydropyridine CCBs can be used if still uncontrolled
therapy for HTN with HFrEF (HF with reduced Ejection Fraction)
- Follow most recent guidelines
- Avoid non-dihydropyridine CCBs due to no clinical benefit/worse outcomes in pts with HF
therapy for HTN with HFpEF (HF with preserved Ejection Fraction)
- Diuretics - fluid overloaded
- ACEi/ARB - elevated BP
- B blockers - elevated heart rate
therapy for HTN with CKD
- CKD stage 1 or 2 AND albuminuria (>300 mg/day or >300 mg/g albumin-creatinine ratio) - ACEi or ARBs
- CKD stage 3 or higher - ACEi or ARBs
- Post kidney transplantation - dihydropyridine CCBs are preferred due to improved GFR and kidney survival
therapy for HTN with cerebrovascular disease
For secondary stroke prevention - ACEi/ARB, thiazide, combo of above
when is it not useful to start therapy on pts with HTN with cerebrovascular disease
if BP is <140/90
therapy for HTN with diabetes
- all first line classes of antihypertensive meds are useful and effective
- in the presence of albuminuria, use ACEi or ARB
preferred agents for pregnant pts
methydopa, nifedipine, labetalol
CI agents in pregnant pts
ACEi, ARBs, direct renin inhibitors.
Thiazides aren’t CI, but not preferred.
therapy for black adult pts with HTN but w/o HF or CKD
initial antihypertensive tx should include a thiazide diuretic or CCB
(unless albuminuria)
diuretics in HTN - initial anti-hypertensive effects
diuresis -> reduced stroke volume -> increased peripheral vascular resistance
diuretics in HTN - chronic anti-hypertensive effects
stroke volume returns to normal -> decrease in peripheral vascular resistance
thiazide diuretics agents
hydrochlorothiazide (HCTZ), chlorthalidone, indapamide, metolazone
what are thiazides more effective than
more effective than loop diuretics if CrCl >30 ml/min
when do you take thiazides
in the morning to avoid nocturnal diuresis
what is the frequency of all thiazides
1/day
thiazides AEs
hypokalemia, hypomagnesemia, hypercalcemia, hyperuricemia, hyperglycemia, hyperlipidemia, sexual dysfunction, increase in TGs/cholesterol
thiazide drug interactions
lithium toxicity with concurrent use
thiazide CIs
sulfa allergy, anuria
loop diuretics agents
furosemide, torsemide, bumetanide, ethacrynic acid
are loop diuretics first line for HTN and if not, what is it used for
NOT first line.
It is preferred in HF for Sx management and more effective than thiazides with CrCl <30 ml/min.
What is the “high-ceiling” dose response curve relevant to loop diuretics?
- May need higher doses with severely reduced renal function or fluid overload
- Switching to another loop diuretic or from PO to IV can help
When should pts take loop diuretics and why
Dose in the morning or afternoon to avoid nocturnal diuresis
What is the furosemide frequency
1 or 2 /day
What is torsemide frequency
1/day
What is bumetanide frequency
1 or 2 /day
Loop diuretics AEs
Hypokalemia, hypomagnesemia, hypocalcemia, hyperuricemia, ototoxicity
Loop diuretics CI
Sulfa allergy
What are the aldosterone antagonists
Spironolactone, eplerenone
Which aldosterone antagonist is preferred with resistant HTN
Spironolactone
What trial found that spironolactone is preferred with resistant HTN
PATHWAY-2 trial
What AE is specific to spironolactone
Gynecomastia and it develops in up to 10% of pts
What can you do if pt is experiencing gynecomastia from spironolactone
Can switch to eplerenone
When should aldosterone antagonist not be initiated
If potassium is > 5 mEq/L
When should aldosterone antagonists be initiated
Dose in the morning or afternoon to avoid nocturnal diuresis
What is spironolactone frequency
1 or 2 /day
What is eplerenone frequency
1 or 2 /day
When should aldosterone antagonists be held or dose reduced
If potassium is > 5.5 mEq/L or SCr increase >25%
Aldosterone antagonists AEs
Hyperkalemia, hyponatremia, gynecomastia in spironolactone
Aldosterone antagonists drug interactions
ACEI/ARBs/renin inhibitors/NSAIDs - increase risk of hyperkalemia
Eplerenone specific CIs
- Impaired renal function (CrCl <50 ml/min or SCr >2 in males or >1.8 in females
- T2DM and proteinuria
Aldosterone antagonists CIs
Concomitant use w/ potassium sparing diuretics - risk of hyperkalemia
K sparing diuretics agents
Amiloride, triamterene
Caution with K sparing diuretics
Caution with pts with diabetes or CKD (GFR <45 ml/min)
What is K sparing diuretics effects
- Minimal BP effects
- used in combination with thiazide to minimize hypokalemia
Amiloride frequency
1 or 2 /day
Triamterene frequency
1 or 2 /day
K sparing diuretics AEs
Hyperkalemia, increased uric acid, hyperglycemia
General diuretic monitoring
When do you not give diuretics
Do not give at bedtime
What is the first line diuretics for most HTN pts
Thiazides
Which diuretic should not be used as monotherapy for HTN
K sparing diuretics
What antihypertensive drug class should be avoided in patients with gout
Thiazide diuretics
