Therapeutics of HTN pt. 3 Flashcards
Angiotensin converting enzyme inhibitors (ACEi) moa
Inhibits conversion for angiotensin I to angiotensin II
Angiotensin II receptor blockers (ARBs) moa
Block effects of angiotensin II by binding to target receptors
Renin inhibitors moa
Inhibits conversion of angiotensinogen to angiotensin I
What is ACEi
first line tx option for HTN
ACEi have additional benefit in pts with history of:
pts with DM w/ proteinuria, HF, post MI, CKD
what is the only ACEi that has frequency of 2 or 3 /day
Captopril
what is the ACEi that has frequency of 1 or 2 /day
Benazepril, Enalapril, Ramipril, Moexipril, Quinapril,
which ACE inhibitors have frequency of 1/day
Fosinopril, Lisinopril, Perindopril, Trandolapril
ACEi AEs
angioedema, cough (up to 20%), hyperkalemia, acute renal failure w/ severe bilateral renal artery stenosis
ACEi CIs
- history of angioedema on an ACEi
- concomitant use of aliskiren in pts w/ DM
- pregnancy/breastfeeding
what is ARBs
first line tx option for HTN
when are ARBs used
often “back up” if an ACEi isn’t tolerated for other indications
why are ARBs often a back up to ACEi
- doesn’t block bradykinin breakdown -> less cough than ACEi
- can use with hx of angioedema due to ACEi
why are ARBs a good option for PM dosing
ensures BP dipping overnight
which are the only ARBs have a frequency of 1 or 2 /day
Eprosartan, Losartan
ARBs AEs
angioedema, hyperkalemia, acute renal failure w/ severe bilateral renal artery stenosis
ARBs CIs
- history of angioedema on ARB
- concomitant use of aliskiren in pts w/ DM
- pregnancy/breastfeeding
ACEi/ARB monitoring
when should ACEi/ARBs doses be possibly held or reduced
if K >5.5 mEq/L or SCr increase >30%
what is the direct renin inhibitor agent
aliskiren
is aliskiren a first line tx option for HTN
No
why does aliskiren produce less cough than ACEi
doesn’t block bradykinin breakdown
aliskiren CIs
- pregnant pts
- concomitant use with an ACEi or ARB contraindicated in pts w/ DM
aliskiren frequency
1/day
what labs should be monitored in pts using aliskiren
K, BUN, SCr
aliskiren AEs
diarrhea, musculoskeletal effects, dizziness, headache, hyperkalemia, renal insufficiency, orthostatic hypotension
CCBs moa
Inhibit influx of calcium across cardiac and smooth muscle cell membranes -> coronary and peripheral vasodilation
CCBs subclasses and effects
- Dihydropyridines - more vasodilation
- Nondihydropyridines - more negative ionotropic effects
- Overall similar effect on BP
Are CCBs first line for HTN
Yes
what pt populations do dihydropyridine CCBs provide additional benefit
Pts with:
- Reynaud’s syndrome
- elderly pts w/ isolated systolic HTN
what dihydropyridines should be avoided
short-acting (IR nifedipine/nicardipine)
how does dihydropyridine CCBs cause vasodilation
through baroreceptor-mediated tachycardia
what does dihydropyridine CCBs not have an effect on
no effect on atrioventricular node conduction
which dihydropyridine CCBs have a frequency of 2/day
Isradipine, Nicardipine SR
dihydropyridine CCBs AEs
reflex tachycardia, flushing, dizziness, headache, peripheral edema (dose related), gingival hyperplasia
dihydropyridine CCBs warning
increased risk of angina/MI in pts with obstructive coronary disease due to reflex tachycardia
dihydropyridine CCBs drug interactions
- grapefruit juice
- CYP3A4 enzyme inducers/inhibitors
what pt populations do nondihydropyridine CCBs provide additional benefit
pts with:
- supraventricular tachyarrhythmias (Afib)
- pts w angina who can not tolerate a B blocker
why do nondihydropyridine CCBs have negative ionotropic effects
slows AV node conduction and decreases HR
what nondihydropyridine CCBs formulations are preferred for HTN
extended release formulations
what is frequency of nondihydropyridine CCBs
1 or 2 /day
what are the nondihydropyridine CCBs agents
Diltiazem ER, Verapamil ER
why are nondihydropyridine CCBs not interchangeable
due to differences in release mechanisms and bioavailability
nondihydropyridine CCBs AEs
bradycardia, headache, dizziness, AV node block, systolic HF, gingival hyperplasia, constipation (verapamil>diltiazem)
nondihydropyridine CCBs drug interactions
- concomitant use of B blockers - increases risk of heart block
- grapefruit juice
- CYP3A4 enzyme inducers/inhibitors
nondihydropyridine CCBs CIs
- heart block
- left ventricular dysfunction
are routine lab monitoring required for CCBs
No
what CCB is preferred in the setting of HF
amlodipine
are B blockers first line for HTN
NOT first line unless a compelling indication is present
what pt populations get additional benefit from B blockers
Pts with:
- tachyarrhythmias
- tremors
- migraines
- thyrotoxicosis
what cardioselective B blocker has a frequency of 2/day
Metoprolol tartrate
what nonselective B blocker has a frequency of 2/day
Propranolol IR
what are the intrinsic sympathomimetic activity (ISA) B blockers
- Acebutolol (frequency of 2/day)
- Penbutolol (frequency of 1/day)
- Pindolol (frequency of 2/day)
what are the mixed alpha/beta B blockers
- Carvedilol (frequency of 2/day)
- Labetalol (frequency of 2/day)
B blockers AEs
Bronchospasms, bradycardia, fatigue, exercise intolerance, depression
what is problem with B blockers
can mask signs/Sx of hypoglycemia
use B blockers with caution in pts with:
- peripheral artery disease
- reactive airway disease
what B blocker is preferred in pts with peripheral artery disease
carvedilol
what B blocker is preferred in pts with reactive airway disease
selective B blockers
B blockers CIs
- second or third degree heart block
- decompensated HF
- post MI (ISA B blockers only)
- severe bradycardia
- sick sinus syndrome
