Hypertension 102

Question 1

Approximately how many mm Hg decrease can you expect to get by adding Spironolactone as fourth agent?

Answer 1

~ 20 point decrease when added to 3 existing agents

Question 2

In which patients should you avoid spironolactone?

Answer 2

Any patient with K >5
Any patient with Cr > 2.5
Have to consider risk of gynecomastia in male patients

Question 3

What are the five classes of drugs that you can use as fourth agent for HTN (after thiazide, ACE/ARB and CCB)?

Answer 3

aldosterone antagonists - spironolactone
Vasodilatory BB - Carvedilol, nebivolol, labetalol
Clonidine
Alpha blockers
Direct vasodilators - Minoxidil and hydralazine

Question 4

Describe how to start spironolactone? What dose do you use and what labs do you get and when?

Answer 4

Start at 12.5 mg and double dose every 2 weeks (takes 2 weeks to appreciate effect)
Must stop for SCr increase to > 4 or K >5 for this reason you have to monitor BMP closely
Check BMP at 1 week, then monthly for 3 months then every 3 months for 1 year then yearly

Question 5

What are two advantages of vasodilatory beta blockers over other beta blockers?

Answer 5

More significant BP reduction

Not associated with new onset DM

Question 6

Name some uses for Clonidine other than HTN.

Answer 6

off label use in ADHD and for sleep in pediatrics, migraine prophylaxis, restless leg syndrome, smoking cessation, excessive sweating salivation, opiate/ETOH withdrawal symptoms

Question 7

Name 4 important side effects of Clonidine

Answer 7

Rebound HTN with sudden withdrawal for this reason it is not a good choice for patient with compliance issues
Dry mouth - 40%
Drowsiness - 33%
Dizziness - 16%

Question 8

What are the pros and cons of using alpha blockers?

Answer 8

Pro- may help men with BPH

Cons - not very powerful antihypertensive, associated with orthostasis so should avoid in elderly

Question 9

What are the side effects of direct vasodilators (Minoxidil and Hydralazine)?

Answer 9

edema and tachycardia which have to be mediated by furosemide and BB
hirsutism with minoxidil
generally use this last of all the 4th line agents

Question 10

What is “dipping” with regards to HTN?

Answer 10

Improved cardiovascular outcomes when overnight BP is controlled. New recommendation that at least one antihypertensive given at night

Question 11

Every morning your patient is taking HCTZ 25mg, Lisinopril 20mg , Amlodipine 10 mg and Atenolol 100 mg what 4 things can you do to improve BP without adding another class of medication?

Answer 11

Maximize dosages - increase lisinopril to 40mg
Address dipping - move one medication to PM
Change HCTZ to chlorthalidone because it is more powerful
Change atenolol which is weak antihypertensive to vasodilatory BB like carvedilol (superior BP lowering, added benefit of alpha blockade, no MM data for atenolol)

Question 12

When should you consider referral to renal for resistant HTN?

Answer 12

For any patient with CKD

In patient on maximal dose of four agents including thiazide who is not controlled

Question 13

When should you consider work-up for secondary causes of HTN?

Answer 13

In any patient with clinical suspicion for secondary cause
At the time of diagnosis of HTN you should think through possible secondary causes
In any patient on maximal doses of 3 agents usually thiazide, ACE/ARB and CCB

Question 14

What is the work up for secondary causes of HTN?

Answer 14

Consider compliance
Consider medications that cause HTN (NSAIDs, OCP, prednisone, illicit drugs, amphetamines, high dose Effexor)
Check the following labs on everyone (CMP - looking for Cushing’s renal disease, UA - renal disease, TSH - thyroid disease, PTH - hyperparathyroidism)
Consider adding aldosterone
Consider sleep apnea order sleep study
Renal ultrasound with doppler looking for renal vascular disease
ECHO - coarctation of aorta
Consider pheochromocytoma - if patient c/o flushing palpitations and has big swings in BP

Question 15

Which medication class should be avoided in women of reproductive age and what is the exception to the rule?

Answer 15

ACE/ARB

Unless they have diabetes and they should then have extensive counseling and consider dual contraception

Question 16

Is it the estrogen or the progesterone that causes HTN in OCP users?

Answer 16

Progestins seem to be the problem.
If elevation is mild could consider going to lower progestin containing pill. If HTN persists have to stop OCP
As patient’s age on OCPs they may develop HTN related to progetins even if they have been on OCP for years without problem

Question 17

You are considering starting a male patient on aldosterone antagonist and he asks about gynecomastia. How do you counsel him?

Answer 17

10% of men get gynecomastia on spironolactone related to dose and duration of use.
Gynecomastia is not always reversible
Epelerone does not have this side effect but is more expensive than spironolactone

Question 18

What is definition of resistant HTN?

Answer 18

Inability to achieve BP goal in patient on full dosage of 3 drug regimen including a diuretic.

Question 19

What are some common causes of resistant HTN (not diesases that are secondary causes of HTN)?

Answer 19

inadequate diuretic
excess sodium
white coat HTN
non adherence
weight gain
excess alcohol
drug interactions

Question 20

Of the “fourth agents” (adosterone antagonists, vasodilatory BB, clonidine, alpha blockers and direct vasodilators) which is least helpful and why?

Answer 20

Direct vasodilators - because they have the most difficult to manage side effect profile. They cause edema and tachycardia and require concomitant treatment with furosemide and BB
Exception is in African Americans combination of hydralazine and nitrates has been found to be very effective in this population this might be you first choice for fourth medication

Question 21

Of the “fourth agents” (aldosterone antagonists, vasodilatory BB, clonidine alpha blockers and direct vasodilators) which two are the worst in the elderly and should be avoided?

Answer 21

direct vasodilators - Minoxidil and Hydralazine
alpha blockers
increase risk for orthostasis and falls
none of the fourth agents are great in the elderly, consider if you are using an appropriate goal - you should accept higher blood pressures in the elderly