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PHRM 844 > Therapeutics of HTN pt. 2 > Flashcards

Therapeutics of HTN pt. 2 Flashcards

1
Q

what does the ALLHAT trial stand for

A

Antihypertensive and lipid lowering treatment to prevent heart attack trial

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2
Q

what is the subject population in the ALLHAT trial

A

42,418 pts age >55 yo with HTN and 1 additional CV risk factor

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3
Q

what were the medication arms in the ALLHAT trial

A

Chlorthalidone, lisinopril based therapy, amlodipine, doxazosin

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4
Q

what was the result of the ALLHAT trial

A

Chlorthalidone > amlodipine and lisinopril based therapy in preventing stroke, heart attacks, and HF
*doxazosin arm stopped early due to increased risk of HF

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5
Q

what are the key takeaways from the ALLHAT trial

A
  1. thiazide diuretics should be first line
  2. for pts who cannot take a diuretic, consider prescribing a CCB or ACEi
  3. most pts with high BP need more than one drug
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6
Q

what are the preferred combination therapies

A

ACEi/CCB, ARB/CCB, ACEi/diuretic, ARB/diuretic

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7
Q

what is acceptable combination therapy

A

CCB/diuretic

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8
Q

first line for HTN with stable ischemic heart disease

A

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

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9
Q

therapy for HTN with HFrEF (HF with reduced Ejection Fraction)

A
  1. Follow most recent guidelines
  2. Avoid non-dihydropyridine CCBs due to no clinical benefit/worse outcomes in pts with HF
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10
Q

therapy for HTN with HFpEF (HF with preserved Ejection Fraction)

A
  1. Diuretics - fluid overloaded
  2. ACEi/ARB - elevated BP
  3. B blockers - elevated heart rate
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11
Q

therapy for HTN with CKD

A
  1. CKD stage 1 or 2 AND albuminuria (>300 mg/day or >300 mg/g albumin-creatinine ratio) - ACEi or ARBs
  2. CKD stage 3 or higher - ACEi or ARBs
  3. Post kidney transplantation - dihydropyridine CCBs are preferred due to improved GFR and kidney survival
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12
Q

therapy for HTN with cerebrovascular disease

A

For secondary stroke prevention - ACEi/ARB, thiazide, combo of above

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13
Q

when is it not useful to start therapy on pts with HTN with cerebrovascular disease

A

if BP is <140/90

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14
Q

therapy for HTN with diabetes

A
  1. all first line classes of antihypertensive meds are useful and effective
  2. in the presence of albuminuria, use ACEi or ARB
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15
Q

preferred agents for pregnant pts

A

methydopa, nifedipine, labetalol

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16
Q

CI agents in pregnant pts

A

ACEi, ARBs, direct renin inhibitors.
Thiazides aren’t CI, but not preferred.

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17
Q

therapy for black adult pts with HTN but w/o HF or CKD

A

initial antihypertensive tx should include a thiazide diuretic or CCB
(unless albuminuria)

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18
Q

diuretics in HTN - initial anti-hypertensive effects

A

diuresis -> reduced stroke volume -> increased peripheral vascular resistance

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19
Q

diuretics in HTN - chronic anti-hypertensive effects

A

stroke volume returns to normal -> decrease in peripheral vascular resistance

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20
Q

thiazide diuretics agents

A

hydrochlorothiazide (HCTZ), chlorthalidone, indapamide, metolazone

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21
Q

what are thiazides more effective than

A

more effective than loop diuretics if CrCl >30 ml/min

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22
Q

when do you take thiazides

A

in the morning to avoid nocturnal diuresis

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23
Q

what is the frequency of all thiazides

A

1/day

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24
Q

thiazides AEs

A

hypokalemia, hypomagnesemia, hypercalcemia, hyperuricemia, hyperglycemia, hyperlipidemia, sexual dysfunction, increase in TGs/cholesterol

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25
Q

thiazide drug interactions

A

lithium toxicity with concurrent use

26
Q

thiazide CIs

A

sulfa allergy, anuria

27
Q

loop diuretics agents

A

furosemide, torsemide, bumetanide, ethacrynic acid

28
Q

are loop diuretics first line for HTN and if not, what is it used for

A

NOT first line.
It is preferred in HF for Sx management and more effective than thiazides with CrCl <30 ml/min.

29
Q

What is the “high-ceiling” dose response curve relevant to loop diuretics?

A
  • May need higher doses with severely reduced renal function or fluid overload
  • Switching to another loop diuretic or from PO to IV can help
30
Q

When should pts take loop diuretics and why

A

Dose in the morning or afternoon to avoid nocturnal diuresis

31
Q

What is the furosemide frequency

A

1 or 2 /day

32
Q

What is torsemide frequency

A

1/day

33
Q

What is bumetanide frequency

A

1 or 2 /day

34
Q

Loop diuretics AEs

A

Hypokalemia, hypomagnesemia, hypocalcemia, hyperuricemia, ototoxicity

35
Q

Loop diuretics CI

A

Sulfa allergy

36
Q

What are the aldosterone antagonists

A

Spironolactone, eplerenone

37
Q

Which aldosterone antagonist is preferred with resistant HTN

A

Spironolactone

38
Q

What trial found that spironolactone is preferred with resistant HTN

A

PATHWAY-2 trial

39
Q

What AE is specific to spironolactone

A

Gynecomastia and it develops in up to 10% of pts

40
Q

What can you do if pt is experiencing gynecomastia from spironolactone

A

Can switch to eplerenone

41
Q

When should aldosterone antagonist not be initiated

A

If potassium is > 5 mEq/L

42
Q

When should aldosterone antagonists be initiated

A

Dose in the morning or afternoon to avoid nocturnal diuresis

43
Q

What is spironolactone frequency

A

1 or 2 /day

44
Q

What is eplerenone frequency

A

1 or 2 /day

45
Q

When should aldosterone antagonists be held or dose reduced

A

If potassium is > 5.5 mEq/L or SCr increase >25%

46
Q

Aldosterone antagonists AEs

A

Hyperkalemia, hyponatremia, gynecomastia in spironolactone

47
Q

Aldosterone antagonists drug interactions

A

ACEI/ARBs/renin inhibitors/NSAIDs - increase risk of hyperkalemia

48
Q

Eplerenone specific CIs

A
  • Impaired renal function (CrCl <50 ml/min or SCr >2 in males or >1.8 in females
  • T2DM and proteinuria
49
Q

Aldosterone antagonists CIs

A

Concomitant use w/ potassium sparing diuretics - risk of hyperkalemia

50
Q

K sparing diuretics agents

A

Amiloride, triamterene

51
Q

Caution with K sparing diuretics

A

Caution with pts with diabetes or CKD (GFR <45 ml/min)

52
Q

What is K sparing diuretics effects

A
  • Minimal BP effects
  • used in combination with thiazide to minimize hypokalemia
53
Q

Amiloride frequency

A

1 or 2 /day

54
Q

Triamterene frequency

A

1 or 2 /day

55
Q

K sparing diuretics AEs

A

Hyperkalemia, increased uric acid, hyperglycemia

56
Q

General diuretic monitoring

A
57
Q

When do you not give diuretics

A

Do not give at bedtime

58
Q

What is the first line diuretics for most HTN pts

A

Thiazides

59
Q

Which diuretic should not be used as monotherapy for HTN

A

K sparing diuretics

60
Q

What antihypertensive drug class should be avoided in patients with gout

A

Thiazide diuretics

PHRM 844 (13 decks)

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