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PHRM 844: Therapeutics II > Therapeutics of Hypertension > Flashcards

Therapeutics of Hypertension Flashcards

1
Q

What are the long term complications of HTN?

A

Left Ventricular Hypertrophy, MI, Heart Failure, Stroke, CKD, Retinopathy.

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2
Q

What is Essential Hypertension?

A

Elevated blood pressure with an unknown etiology?

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3
Q

What is Secondary Hypertension?

A

Elevated blood pressure do to concurrent medical conditions or medications [Identifiable]

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4
Q

What is Isolated Systolic Hypertension?

A

Systolic BP levels are high BUT not diastolic BP is not

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5
Q

What is Resistant Hypertension?

A

Failure to attain goal BP while having at least 3 agent at max dose or when 4 or more agents are needed.

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6
Q

What is Orthostatic Hypotension?

A

A systolic blood pressure decrease of > 20mmHg, a distolic blood pressure decrease of > 10mmHg within three minutes of changing position

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7
Q

What are the risk factors associated with HTN?

A

Modifiable: Increased Na Intake, Obesity, Increased OH Intake, Decreased K Intake
Non-modificable: Age, Gender, Genetics, Race

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8
Q

Substances that can Increase Blood Pressure?

A

Ilicit Drugs [Cocaine, Ecstasy], Caffeine, Nicotine, Decongestants [phenylephrine, Psudeophed], Amphetamines, NSAIDS [Ibuprofen, neproxan…], Steriods, Contraceptives.

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9
Q

Measurements of Blood Pressure?

A

In Office: Should take 2 reading five minutes apart
Ambulatory: for “White Coat HTN” & may help with nighttime dippings
Home: for “White Coat HTN” & may help with adherence and response

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10
Q

What patterns are seen with the measurements of HTN?

A

Normotensive: NO HTN anywhere
Sustained: HTN both
Masked: HTN at Home
White Coat: HTN at Clinic

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11
Q

What is the classifications of Blood Pressure?

A

Normal: <120 / <80
Elevated: 120-129 / <80
Stage 1: 130-139 / 80-89
Stage 2: >140 / >90
[If one or the other falls down into a different category, always pick the higher]

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12
Q

What is the Blood Pressure reduction strategy for a Normal Pressure?

A

Keep promoting a health lifestyle and check back in 1 YEAR.

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13
Q

What is the Blood Pressure reduction strategy for an Elevated Pressure?

A

Start a NON-PHARM therapy and check back in 3-6 months

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14
Q

What is the Blood Pressure reduction strategy for Stage 1 Hypertension?

A

Check the patients ASCVD risk AND if they have any comorbidity:
Yes: Start NON-PHARM & PHARM and check back in 1 months
No: Start NON-PHARM and check back in 3-6 months

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15
Q

What are the comorbidities of HTN?

A

-Clinical CVD or ASCVD risk > 10%, Age > 45, Diabetes, Stoke, MI, Heart Failure, CKD [>130/>80]
-No Clinical CVD and ASCVD risk > 10%, Secondary Stroke Prevention [>140/>80]

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16
Q

What is the Blood Pressure reduction strategy for Stage 2 HTN?

A

`Start NON-PHARM & 2 MEDICATIONS and check back in 1 month

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17
Q

Blood Pressure Goals?

A

ACC/AHA: <130/80
- Elderly <140/90
ADA: <140/90
KDGO: <120/80

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18
Q

What happened within the SPRINT trial?

A

Tested patients WITHOUT diabetes or prior to stroke. Showed that CV problems were decrease by 25% in the intensive group = this is the reason why we use to medications

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19
Q

What are some Non-pharmacological treatment options for HTN?

A

Weight loss, DASH diet, exercise, decrease Na, Increase K, Decrease OH…

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20
Q

What is the ACC/AHA recommendation for the Initial Antihypertensive medicaiton?

A

Thiazides
-CCB, ACE-I, and/or ARBs are also considered first line treatment too.

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21
Q

Why are Thiazides considered the first line therapy?

A

Due to the ALLHAT trial; it showed that cholthalidone [diuretic] worked better than the other medications at preventing stroke, HA, and HF.
*Most patients are going to need combo therapy for HTN

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22
Q

Are all combinations acceptable?

A

NO ACEi/ARBs
-Only CCB/Diuretic are acceptable
-Preferred: ACE/CCB, ARB/CCB, ACE/Diuretic, ARB/Diuretic

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23
Q

Can you give an ACE with and ARB?

A

NO!
-Too many adverse effects for CV and Renal

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24
Q

Patient specific factors for Stable Ischemic Heart Diseases?

A

First Line: Beta-Blockers [Can also use ACE or ARBs]
- If uncontrolled use CCBs

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25
Q

Patient specific factors for Heart Failure?

A

No really medications, just manage symptoms
-Diuretics: Fluids; ACE/ARBs: BP; Beta-Blockers: HR
*DO NOT USE NON-DHP: no clinical benefit

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26
Q

Patient specific factors for CKD?

A

CKD stage 1 or 2 AND albuminuria: use ACEi
CKD stage 3 or higher: use ACEi
*After transplant: use CCB [Improved liver
function]
*ARBs are only used when intolerant to ACEi

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27
Q

Patient specific factors for Cerebrovascular Disease?

A

Start with Thiazide Diuretics then add ACEi/ARBs
*Could use a combo of both

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28
Q

Patient specific factors for Diabetes?

A

ALL first-line therapies are good
*If albuminuria: ACEi/ARBs

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29
Q

Patient specific factors for Pregnancy?

A

Preferred to use Methyldopa, Labetalol, Nifedipine
*CONTRAINDICATED: ACEi, ARBs, Renin Inhibitors

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30
Q

Patient specific factors for Race?

A

In black adults: use thiazide or CCB UNLESS they have HF or CKD

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31
Q

What are the Thiazide Diuretics?

A

HCTZ, Chorlthalidone, Inpadaide, Metolazone
-Chlorthalidone is more potent than HCTZ

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32
Q

Are the Thiazides the first line therapy?

A

YES!
-ALLHAT trial proves this

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33
Q

When should Thiazide Diuretics be taken? What is the frequency of Thiazide Diuretics?

A

Taken ONCE in the morning to avoid nighttime urination

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34
Q

What are the side effects of Thiazides?

A

Changes in electrolytes [Low K, Low Mg, High Ca], Hyperuricemia, increase in triglycerides
*CONTRAINDICATED: sulfa allergy

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35
Q

What are the Loop Diuretics?

A

Furosemide, Torsemide, Bumetanide, Ethacrynic Acid [not a sulfa]

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36
Q

Are the Loop Diuretics first-line therapy for HTN?

A

NO!
-Can be used in management for Heart Failure

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37
Q

What is the dosing Loop Diuretics and when should they be taken?

A

Furosemide & Bumetanide are ONCE or BID while Torsemide is ONCE daily.
-Should be taken in the AM or afternoon

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38
Q

What are the side effects of Loop Diuretics?

A

Low Ca, Low K, Low Mg, Low urea
*CONTRAINDICATION: sulfa allergy

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39
Q

What are the Aldosterone Antagonists?

A

Spironolactone, Eplerenone

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40
Q

What is Spironolactone preferred in?

A

Resistant HTN

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41
Q

What is the frequency of spironolatcone
and when should it be dosed?

A

Both are taken ONCE or BID and should be taken within the AM or afternoon

42
Q

What are the side effects of Aldosterone Antagonist?

A

Hyperkalemia [consider holding], hyponatremia, gynecomastia [spironolactone only]

43
Q

What are the drug interactions with Aldosterone Antagonist?

A

ACEi, ARBs, Renin Inhibitors, NSAIDS
-Will increase Hyperkalemia

44
Q

What are the Potassium Sparing Diuretics?

A

Amiloride, Triamterne

45
Q

How are the Potassium Sparing Diuretics used?

A

Have a minimal BP affect, SO use with Thiazides to minimize Hypokalemia

46
Q

What is the frequency and how are Potassium Sparing Diuretics used?

A

Both are taken ONCE or BID and should be taken in the AM to reduce the nighttime urination.

47
Q

What are the ACEi?

A

The “-prils”
-Benazepril, Captopril, Enalaprol, Fosinopril, Lisinopril, Moexipril, Perindopril…

48
Q

What are the ACEi good in?

A

-Diabetes with Proteinuria
-HF [Management]
-MI [Ishcemia]
-CKD [All stages]

49
Q

What is the frequency and when should the ACEi be used?

A

-Should be taken in the PM to reduce BP dipping
-Most are ONCE or BID but Captopril is BID or TID

50
Q

What is the MOA of ACEi?

A

They inhibit the production of Angiotensin II from Angiotensin I

51
Q

What are the side effects of ACEi?

A

Dry Cough (20%), Angioedema, Hyperkalemia, Acute Renal Failure
*CONTRAINDICATION: Hx of Angioedema, Pregnancy/Breastfeeding

52
Q

What are the ARBs?

A

The “-sartans”
-Azilsartan, Candesartan, Eprosartans, Irbesartan, Losartan, Olmesartan, Telmisartan, Valsartan

53
Q

What are the ARBs good with?

A

-Can be used if ACEi intolerance
-Doesn’t cause the breakdown on bradykinin = no dry cough
-Can use with Hx of Angioedema by ACEi

54
Q

What is the frequency and when should ARBs be taken?

A

-All are dosed ONCE daily except for Eprosartan & Losartan; they can be dosed ONCE or BID.
-They should be taken at PM to reduce BP dipping

55
Q

What are the side effects of ARBs

A

Have the same AE as ACEi just without the Dry Cough; [Hyperkalemia, angioedema]
*CONTRAINDICATIONS: angioedema with ARB, Pregnancy/Breastfeeding

56
Q

What should you do if a patients K is too high while taking a ACEi or ARB?

A

Hold it until K levels go back down

57
Q

What are the Direct Renin Inhibiters?

A

Aliskiren

58
Q

What is the MOA of the Direct Renin Inhibitors?

A

Blocks the conversion of Angiotensinogen to Angiotensin I = Stoping the production of Angiotensin II

59
Q

What is unique about the Aliskiren?

A

-NOT first line = very expensive
-Does not break down Bradykinin = not dry cough
-Should not use with ACEi or ARBs in diabetes

60
Q

What is the frequency and the dosing for Aliskiren?

A

Should be taken ONCE daily and taken in the AM?

61
Q

What are the side effects of the Direct Renin Inhibitors?

A

Diarrhea, Dizziness, Headache, Hyperkalemia, Orthostatic Hypotension
*CONTRAINDICATED: pregnancy

62
Q

What are some counseling tips for the ACEi, ARBs, and Aliskiren?

A

-DO NOT take while pregnant
-Hyperkalemia: AVOID high potassium foods
-ACEi and ARBs are often preferred

63
Q

What is the MOA for the Calcium Channel Blockers [CCB]?

A

They inhibit the influx of Calcium across cardiac and smooth muscle cell membranes causing vasodilation

64
Q

What are the 2 subclasses of CCB?

A

Dihydropyridines & Non-dihydropyridines

65
Q

What are the Dihydropyridines?

A

The “-pines”
-Amlodipine, Felodipine, Isradipine, Isradipine SR, Nicardipine SR, Nifedipine LA, Nisoldipine

66
Q

What are the DHP beneficial in?

A

Good in patients that have Raynauds Syndrome & Elderly Patients with Isolated Systolic HTN
*More potent than Non-DHP

67
Q

What are the side effects of DHP?

A

Reflex Tachycardia [Short Acting], Flushing Headache, Dizziness, Edema

68
Q

What are the drug interactions with DHP?

A

CYP3A4, Grapefruit Juice

69
Q

How are the DHP taken?

A

ALL are taken ONCE daily except for Isradipine & Nicardipine SR; they are taken BID

70
Q

What are the Non-DHP?

A

Verapamil and Diltiazem

71
Q

What are Non-DHP beneficial in?

A

Patients with Afib and those with angina who can’t tolerate a Beta-Blocker

72
Q

What is the MOA of Non-DHP?

A

Will slow down the SV node causing a decrease in heart rate = decreasing CO = decreasing BP

73
Q

What is the frequency of Verapimil and Diltiazem?

A

Both are taken ONCE or BID

74
Q

What are the side effects of Non-DHP?

A

Bradycardia [Slowing down the HR], Headache Dizziness, Constipation [Ver > Dil]
*CONTRAINDICATION: Heart Block, Left Ventricular Dysfunction

75
Q

What are the Drug interaction of Non-DHP?

A

Grapefruit Juice, CYP3A4, Heart Block [Electrical impulses are disrupted]

76
Q

What if a CCB is needed in HF?

A

Use Amlodipine

77
Q

Are the Beta-Blockers first-line therapy?

A

No, they are not first-line UNLESS the patient has HF or CAD

78
Q

What is the MOA of Beta-Blockers?

A

They will decrease the HR [B1] along with the force of contraction [decrease CO] = decrease in BP

79
Q

What are the Cardioselective Beta-Blockers?

A

The “-olol” [B1]
-Atenolol, Betaxolol, Bisoprolol Metoprolol, Nebivolol

80
Q

What is unique about the Cardioselective Bete-Blockers?

A

Since they are B1 selective they will affect the Heart more so it will DECREASE CO better.

81
Q

What are the Nonselective Beta-Blockers?

A

Nadolol, Propranolol

82
Q

What is unique about the Nonselective Beta-Blockers?

A

They affect both B1 and B2… so; it will decrease the HR along with causing possible Bronchospams [Avoid in bronchospastic airway disease]

83
Q

What are the Intrinsic Sympathomimetic Activity Beta-Blockers?

A

Acebutolol, Penbutolol, Pindolol

84
Q

What is unique about the ISA Beta-Blockers?

A

They are to be avoided in patients that have HF and IHD
-Pindolol and Acebutolol are partial agonist

85
Q

What are the mixed Alpha/Beta-Blockers?

A

Carvedilol, Labetalol

86
Q

What is unique about the Mixed Alpha/Beta Blockers?

A

They have A1 so it will cause vasodilation due to the inhibition of Nor-Epi = Decrease VR & CO = Decrease BP

87
Q

What are the side effects of the Beta-Blockers?

A

Bradycardia, Bronchospasms, Fatigue, Exercise Intolerance, Depression.

88
Q

What are the Direct Arterial Vasodilators?

A

Minoxidil, Hydralazine

89
Q

When should Direct Arterial Vasodilators be used in therapy?

A

LAST LINE

90
Q

What should be used with Direct Arterial Vasodilators and why?

A

Use a diuretic and a beta-blocker
-Diuretic: because of the increased H2O retention
-B-Blocker: because of the reflex tachycardia

91
Q

What is the frequency of the Direct Arterial Vasodilators?

A

Minoxidil: ONCE - TID
Hydralazine: BID - 4 TIMES DAILY

92
Q

What are the side effects of Direct Arterial Vasodilators?

A

Tachycardia, Headache, GI Upsets, Chest pain
-Lupus like symptoms/Rash [Hydralazine]
-Hair Growth [Minoxidil]

93
Q

What are some warnings about Direct Arterial Vasodilators?

A

-Should be maxed out on diuretics and 2 antihypertensives before starting
-Need to be use with a Diuretic and Beta-Blocker

94
Q

What are the Alpha-1 Blockers?

A

The “-zosins”
-Prazosin, Doxazosin, terazosin …

95
Q

Are the Alpha-1 Blockers a first line therapy?

A

NEVER a first-line therapy for HTN

96
Q

What do Alpha-1 Blockers work best in?

A

Orthostatic Hypertension [Especially in the Elderly]

97
Q

What are the Central Alpha-2 Agonists?

A

Clonidiene, Methyldopa, Guanfacine

98
Q

When should the Central Alpha-2 Agonists be used in therapy?

A

Last line in HTN due the the side effects

99
Q

What are the side effects of the Central Alpha-2 Agonist?

A

dizziness, fatigue, bradycardia, tachycardia, fluid retention

100
Q

What is the importance of Methlydopa?

A

Can be used in pregnancy

101
Q

What is Resistant Hypertension?

A

Failure to lower BP with 3 maxed out agents or using 4 or more agents at once

102
Q

What is the management of Resistant HTN?

A

-Maximize Lifestyle [Non-pharm] or Optimize 3-drug regimen (ACEi, ARBs, Diuretics, CCB)
-Change out thiazides [HCTZ to Chlorthalidone]
-Add aldersterone antagonist [spironolactone, eplerenone]
-Add Beta-Blocker if HR >70 bpm [use Alpha-2 if BB is contraindicated]
-Add Hydralazine
-Switch Hydralazine to Minoxidil

PHRM 844: Therapeutics II (11 decks)

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