37. Hypertension Flashcards Preview

Pharmacy > 37. Hypertension > Flashcards

Flashcards in 37. Hypertension Deck (82):
1

A 30 year-old female has hypertension and asthma. She is already using hydrochlorothiazide 25 mg daily, but her blood pressure remains elevated at a range of 142-154/84-92 mmHg. She will be started on beta blocker therapy. Which of the following agents is most appropriate?

A. Carteolol
B. Carvedilol
C. Propranolol
D. Metoprolol
E. Timolol

D. With a chronic breathing condition (asthma, COPD, emphysema), the non-selective beta blockers should be avoided.

AMEBBA

Beta Blocking Agents: inhibit effects of catecholamines at beta-1 & beta-2 receptors to reduce BP and HR. Beta blockers with intrinsic sympathomimetic activity (ISA) partially stimulate beta receptors while blocking additional stimulation and are contraindicated in S/P MI patients. ISA agents are carteolol, acebutolol, penbutolol, pindolol (CAPP). Boxed warning: avoid abrupt withdrawal, must taper. CI: sinus bradycardia, 2nd or 3rd degree heart block, sick sinus syndrome, cardiogenic shock, active asthma exacerbation. Warning: caution in diabetes (hypoglycemia), asthma, severe COPD, Raynaud's disease, may mask hyperthryoidism, aggravate psychiatric conditions. SE: decrease HR, hypotension, fatigue, dizziness, depression, decrease libido, impotence, hyperglycemia, hypoglycemia, hypertriglyceridemia, decrease HDL, most pregnancy (C)

Beta-1 selective blockers: AMEBBA.

acebutolol (Sectral): PO

esmolol (Brevibloc): IV

atenolol (Tenormin): PO

betaxolol: PO

bisoprolol (Zebeta): PO

metoprolol tartrate (Lopressor), metoprolol succinate (Toprol XL): PO, IV. Lopressor with food. IV:PO ratio 1:2.5

Beta-1 blocker with nitric oxide-dependent vasodilation

nebivolol (Bystolic): PO. CI in severe liver impairment. caution with 2D inhibitors

Beta-1 & Beta-2 blockers (non-selective)

nadolol (Corgard): PO

penbutolol (Levatol): PO

pindolol: PO

propranolol (Inderal LA, InnoPran XL): PO, IV, solution; most lipophilic, more CNS side effects (sedation, depression, cognitive effects)

timolol: PO

Alpha-1 and non-selective beta blocker

labetalol (Trandate): PO, IV; used commonly in hospital

Non-selective alpha and beta blocker

carvedilol (Coreg): PO. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels

2

A 55 year-old male patient with hypertension was started on lisinopril. He developed severe swelling of his mouth, with trouble breathing. Choose the correct statement:

A. The patient should be switched to Vasotec therapy.
B. The patient should be switched to Atacand therapy.
C. The patient should be switched to Lotrel therapy.
D. The patient should be switched to Exforge therapy.
E. None of the above.

E. The patient developed angioedema from ACE Inhibitor therapy so they should not use any other RAAS inhibitor. It would be best/safest to pick an agent outside of the RAAS inhibitor class.

Vasotec (enalapril)

Atacand (candesartan)

Lotrel (amlodipine/benazepril)

Exforge (amlodipine/valsartan)

2

A 62 year-old female patient comes to the clinic for follow-up evaluation of her osteoporosis. Her BP last vist was 158/92 mmHg and 154/95 mmHg this visit. According to the JNC 8 guidelines, what is this patient's goal BP given she has no other medical conditions?

A. < 140/90 mmHg
B. < 120/80 mmHg
C. < 150/90 mmHg
D. < 140/80 mmHg
E. < 150/80 mmHg

C. Goal BP for this patient is < 150/90 mmHg.

JNC-8

Age 60 and up: BP goal <150/90. Age 18-59 or those with diabetes or CKD regardless of age: <140/90

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

2

A 45 year-old female patient has gone to see her primary care physician. The doctor is looking at her blood work, which includes the following parameters: total cholesterol 202 mg/dL, HDL 52 mg/dL, LDL 130 mg/dL, TG 96 mg/dL, BUN 18 mg/dL, SCr 0.8 mg/dL, hCG+, with a blood pressure of 148/88 mmHg. Which of the following medications can be safely administered?

A. Hydrochlorothiazide
B. Lipitor
C. Zestril
D. Atenolol
E. Tekturna

A. The patient is pregnant (hCG+). She cannot use statins, ACE inhibitors, angiotensin-receptor blockers, direct renin inhibitors, or atenolol. These medications, if used, should be discontinued as soon as pregnancy is detected.

Pregnancy & HTN

Preeclampsia may be managed differently than HTN in pregnancy. Preeclampsia generally includes proteinuria in addtion to high BP.

Stop all teratogenic drugs: ACE-I, ARBs, aliskiren.

Treat when SBP>160 or DBP>105 with labetalol (most favorable), nifedipine ER (moderate SEs), methyldopa (most SEs) with a goal BP of 120-160 SBP and 80-105 DBP.

thiazide-like diuretics: pregnancy (B)

beta-blockers : pregnancy (C)

2

A hospitalized patient was given sodium polystyrene sulfonate this morning. The pharmacist is reviewing her medications. Which of the following medications most likely should be discontinued in this patient?

A. Metoprolol
B. Clopidogrel
C. Olmesartan
D. Clonidine
E. Piperacillin-Tazobactam

C. The patient was given sodium polystyrene sulfonate (Kayexalate), which is used to treat hyperkalemia. Antihypertensive agents that retain potassium include ACEIs, ARBs, direct renin inhibitors, potassium-sparing diuretics and the aldosterone blockers (aldosterone and eplerenone).

Renin-Angiotensin Aldosterone System (RAAS) Inhibitors: ACE-I & ARB

First line in CKD, slow progression of kidney disease, HF, stroke. Do not use ACE-I and ARB together. Avoid in pregnancy (D), angioedema, bilateral renal artery stenosis, or with aliskiren in patients with DM or GFR

benazepril (Lotensin): PO

captopril (Capoten): PO, empty stomach

enalapril, enalaprilat IV (Vasotec): PO, IV, solution

lisinopril (Prinivil, Zestril): PO

moexipril (Univasc): PO, empty stomach

fosinopril (Monopril): PO

perindopril (Aceon): PO

quinapril (Accupril): PO

ramipril (Altace): PO

trandolapril (Mavik): PO

valsartan (Diovan): PO

losartan (Cozaar): PO

irbesartan (Avapro): PO

candesartan (Atacand): PO

olmesartan (Benicar): Sprue-like enteropathy (severe, chronic diarrhea with substantial weight loss) then stop Benicar

telmisartan (Micardis): PO

eprosartan (Teveten): PO

azilartan (Edarbi): PO, keep in original container

3

A patient gave the pharmacist a prescription for clonidine tablets for initial treatment of hypertension. The patient's other medications include polyethylene glycol, fluoxetine and olanzapine (for treatment-resistant depression) and modafinil. The pharmacist should contact the physician to offer the following correct recommendations: (Select ALL that apply.)

A. Clonidine will worsen constipation.
B. Clonidine could worsen depression.
C. Clonidine could worsen fatigue.
D. There is a major drug interaction between clonidine and polyethylene glycol.
E. Clonidine can increase the risk of serotonergic syndrome.

A, B, C. Clonidine is not used first-line and has many side effects that make it a difficult drug for patients to tolerate, including constipation, dry mouth, bradycardia (start QHS), fatigue, lethargy, aggravation of depression and sexual dysfunction/impotence.

Centrally-Acting alpha-2 adrenergic agonist: stimulate alpha-2 in the brain resulting in reduced sympathetic outflow from CNS. CI: methyldopa only (active liver disease, concurrent use with MAO-I). SE: dry mouth, somnolence, headache, fatigue, dizziness, constipation, bradycardia hypotension, depression, behavioral changes, sexual dysfunction; patch (skin rash, pruritis, erythema, contact dermatitis). Methyldopa additional SE: hypersensitivity reactions, hepatitis, myocarditis, positive Coombs, drug-induced fever, drug-induced lupus erythematosus (DILE), can increase prolactin levels. Rebound hypertension if stopped abruptly, must taper. Pregnancy (B/C)

clonidine (Catapres, Duraclon inj): PO, patch, inj. patches Q weekly, remove patch before MRI. only form that comes as a patch in treating BP

guanfacine (Tenex) PO:

methyldopa: PO, inj

4

A patient gave the pharmacist a prescription for Accupril 40 mg PO daily. Which of the following is an appropriate generic substitution for Accupril?

A. Fosinopril
B. Ramipril
C. Triamterene
D. Clonidine
E. Quinapril

E. The generic name of Accupril is quinapril.

fosinopril (Monopril)

ramipril (Altace)

triamterene (Dyrenium)

clonidine (Catapres)

5

A patient gave the pharmacist a prescription for Atacand 8 mg 1 tablet by mouth daily #30. Which of the following is an appropriate generic substitution for Atacand?

A. Valsartan
B. Candasartan
C. Irbesartan
D. Perindopril
E. Labetalol

B. The generic name for Atacand is candasartan.

candesartan (Atacand): PO

valsartan (Diovan)

irbesartan (Avapro)

perindopril (Aceon)

labetalol (Trandate)

5

A patient gave the pharmacist a prescription for Benicar 20 mg by mouth daily #30. Which of the following is an appropriate generic substitution for Benicar?

A. Olmesartan
B. Telmisartan
C. Irbesartan
D. Eprosartan
E. Candesartan

A. The generic name for Benicar is olmesartan.

olmesartan (Benicar): Sprue-like enteropathy (severe, chronic diarrhea with substantial weight loss) then stop Benicar

telmisartan (Micardis)

irbesartan (Avapro)

eprosartan (Teveten)

candesartan (Atacand)

5

A patient gave the pharmacist a prescription for Avapro 150 mg by mouth daily #30. Which of the following is an appropriate generic substitution for Avapro?

A. Amlodipine
B. Irbesartan
C. Verapamil
D. Valsartan
E. Candesartan

B. The generic name of Avapro is irbesartan.

amlodipine (Norvasc)

verapamil (Calan)

valsartan (Diovan)

candesartan (Atacand)

5

A patient gave the pharmacist a prescription for Altace 10 mg PO daily. Which of the following is an appropriate generic substitution for Altace?

A. Minoxidil
B. Ramipril
C. Triamterene
D. Spironolactone
E. Moexipril

B. The generic name of Altace is ramipril.

triamterene (Dyrenium)

spironolaction (Aldactone)

moexipril (Univasc)

6

A patient gave the pharmacist a prescription for Cardizem CD 120 mg 1 PO daily #30. Which of the following is an appropriate generic substitution for Cardizem CD?

A. Amlodipine extended-release capsule
B. Carteolol extended-release capsule
C. Verapamil extended-release capsule
D. Carvedilol extended-release capsule
E. Diltiazem extended-release capsule

E. Be careful when using the orange book to find a suitable generic alternative with diltiazem formulations. Cardizem CD is rated AB3, and needs an AB3 generic. Diltiazem has four different long-acting designations (AB1, AB2, AB3 and AB4).

non-DHP: negative inotrope and negative chronotrope, work peripherally and vasodilate coronary vasculature. both are 3A4 substrate and moderate 3A4 inhibitors. SE: edema, HA, dizziness, AV block, bradycardia, hypotension, arrhythmias, HF, constipation (more with verapamil), gingival hyperplasia, pregnancy (C). Avoid grapefruit juice.

diltiazem (Cardizem): PO, IV

verapamil (Calan): PO, IV requires protection from light during administration

amlodipine (Norvasc)

carvedilol (Coreg)

6

A patient gave the pharmacist a prescription for Catapres 0.1 mg 1 tablet BID #60. Which of the following is an appropriate generic substitution for Catapres?

A. Minoxidil
B. Hydralazine
C. Doxazosin
D. Clonidine
E. Clonazepam

D. The generic name of Catapres is clonidine.

hydralazine (Apresoline)

doxazosin (Cardura)

clonazepam (Klonopin)

6

A patient gave the pharmacist a prescription for Catapres TTS-1 #4. Choose the correct counseling statements for this medication. (Select ALL that apply.)

A. Take this medication by mouth four times daily.
B. This medication can be disposed of in the trash container with a lid.
C. Replace the patch every morning.
D. Rotate the site where you place the patch.
E. This is the highest dose available of this medication.

B, D. The clonidine patch is replaced every seven days. It is available in a higher dose.

7

A patient gave the pharmacist a prescription for Cozaar 50 mg by mouth daily #30. Which of the following is an appropriate generic substitution for Cozaar?

A. Olmesartan
B. Valsartan
C. Irbesartan
D. Losartan
E. Candesartan

D. The generic name of Cozaar is losartan.

olmesartan (Benicar)

valsartan (Diovan)

irbesartan (Avapro)

candesartan (Atacand)

8

A patient gave the pharmacist a prescription for Cozaar she needed filled. Her other medication is Yaz contraceptive pills. The pharmacy is in a supermarket and the pharmacist notices the patient has Morton Salt Balance in her shopping cart, which contains potassium chloride. Which of the following are correct counseling statements for this patient? (Select ALLthat apply.)

A. Your new medication is safe in pregnancy.
B. Yaz can increase potassium.
C. Your new medication can cause a dry, hacking cough.
D. Your new medication, and the salt substitute, can increase your potassium.
E. Your new medication can decrease the effectiveness of Yaz.

B, D. Cozaar can increase the risk of hyperkalemia and is not safe in pregnancy.

9

A patient gave the pharmacist a prescription for Exforge. Which of the following is the generic of Exforge?

A. Amlodipine and benazepril
B. Amlodipine and valsartan
C. Amlodipine, valsartan and hydrochlorothiazide
D. Amlodipine and olmesartan
E. Aliskiren and amlodipine

B. Exforge contains amlodipine and valsartan.

9

A patient gave the pharmacist a prescription for Diovan 80 mg by mouth daily #30. Which of the following is an appropriate generic substitution for Diovan?

A. Candesartan
B. Irbesartan
C. Olmesartan
D. Valsartan
E. Losartan

D. The generic name for Diovan is valsartan.

candesartan (Atacand)

irbesartan (Avapro)

olmesartan (Benicar)

losartan (Cozaar)

11

A patient gave the pharmacist a prescription for Lopressor 50 mg BID #60. Which of the following is an appropriate generic substitution for Lopressor?

A. Metoprolol
B. Bumetanide
C. Triamterene
D. Clonidine
E. Olmesartan

A. The generic name for Lopressor is metoprolol.

Beta Blocking Agents: inhibit effects of catecholamines at beta-1 & beta-2 receptors to reduce BP and HR. Beta blockers with intrinsic sympathomimetic activity (ISA) partially stimulate beta receptors while blocking additional stimulation and are contraindicated in S/P MI patients. ISA agents are carteolol, acebutolol, penbutolol, pindolol (CAPP). Boxed warning: avoid abrupt withdrawal, must taper. CI: sinus bradycardia, 2nd or 3rd degree heart block, sick sinus syndrome, cardiogenic shock, active asthma exacerbation. Warning: caution in diabetes (hypoglycemia), asthma, severe COPD, Raynaud's disease, may mask hyperthryoidism, aggravate psychiatric conditions. SE: decrease HR, hypotension, fatigue, dizziness, depression, decrease libido, impotence, hyperglycemia, hypoglycemia, hypertriglyceridemia, decrease HDL, most pregnancy (C)

Beta-1 selective blockers: AMEBBA.

acebutolol (Sectral): PO

esmolol (Brevibloc): IV

atenolol (Tenormin): PO

betaxolol: PO

bisoprolol (Zebeta): PO

metoprolol tartrate (Lopressor), metoprolol succinate (Toprol XL): PO, IV. Lopressor with food. IV:PO ratio 1:2.5

Beta-1 blocker with nitric oxide-dependent vasodilation

nebivolol (Bystolic): PO. CI in severe liver impairment. caution with 2D inhibitors

Beta-1 & Beta-2 blockers (non-selective)

nadolol (Corgard): PO

penbutolol (Levatol): PO

pindolol: PO

propranolol (Inderal LA, InnoPran XL): PO, IV, solution; most lipophilic, more CNS side effects (sedation, depression, cognitive effects)

timolol: PO

Alpha-1 and non-selective beta blocker

labetalol (Trandate): PO, IV; used commonly in hospital

Non-selective alpha and beta blocker

carvedilol (Coreg): PO. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels

13

A patient gave the pharmacist a prescription for Norvasc 10 mg daily #90. Which of the following is an appropriate generic substitution for Norvasc?

A. Amlodipine
B. Lisinopril
C. Nicardipine
D. Carvedilol
E. Diltiazem

A. The generic name of Norvasc is amlodipine.

amlodipine (Norvasc): least likely to cause reflex tachycardia/flushing, safest in HF patients

lisinopril (Zestril)

nicardipine (Cardene)

carvedilol (Coreg)

diltiazem (Cardizem)

15

A patient gave the pharmacist a prescription for Tenormin 50 mg daily #30. Which of the following is an appropriate generic substitution for Tenormin?

A. Amiloride
B. Eplerenone
C. Atenolol
D. Terazosin
E. Nisoldipine

C. The generic name for Tenormin is atenolol.

amiloride (Midamor)

eplerenone (Inspra)

terazosin (Hytrin)

nisoldipine (Sular)

16

A patient gave the pharmacist a prescription for Zestril 5 mg daily #30. Which of the following is an appropriate generic substitution for Zestril?

A. Quinapril
B. Lisinopril
C. Benazepril
D. Fosinopril
E. Moexipril

B. The generic name for Zestril is lisinopril.

quinapril (Accupril)

benazepril (Lotensin)

moexipril (Univasc)

fosinopril (Monopril)

17

A patient has been started on hydrochlorothiazide 25 mg daily. Which of the following statements are correct? (Select ALLthat apply.)

A. Potassium can decrease
B. Calcium can decrease
C. Uric acid can increase
D. Sodium can increase
E. Magnesium can decrease

A. C. E. Thiazide diuretics can decrease potassium, sodium and magnesium and increase calcium, uric acid, blood glucose and cholesterol.

Thiazide-type Diuretics: inhibit Na reabsorption in the distal convoluted tubules of nephron causing increase excretion of Na, water, K, H+. K-sparing diuretics also work here as well. SE: decrease (K, Mg, Na), increase (UA, LDL, TG, BG, Ca), rash dizziness, photosensitivity, pregnancy (B). Good for the bones unlike loop-diuretics which causes loss of Ca. Take early in the day to avoid nocturia. Do not work when CrCl

chlorthalidone (Thalitone): max 25mg/day (no BP benefit at higher doses), longest half life

hydrochlorothiazide (Microzide, Oretic): max 25-50mg/day (no BP benefit after 25mg)

chlorothiazide (Diuril): PO, IV, suspension

indapamide: data in stroke prevention

metolazone (Zaroxolyn): has additional MoA at proximal tubule

methyclothiazide:

19

A patient has high blood pressure, but a slow heart rate. The patient occasionally suffers from orthostatic hypotension and syncope. The physician is concerned and does not wish to use a blood pressure medication which can lower heart rate. Choose an agent that does not significantly lower heart rate:

A. Nadolol
B. Amlodipine
C. Diltiazem
D. Verapamil
E. Atenolol

B. Beta blockers (without ISA activity) and the non-dihydropyridine calcium channel blockers are anti-hypertensive agents that lower heart rate. This can be useful in a patient with a fast heart rate, or tachycardia. A normal heart rate ranges from 60-100 beats per minute (BPM).

nadolol (Corgard)

amlodipine (Norvasc)

diltiazem (Cardizem)

verapamil (Calan)

atenolol (Tenormin)

21

A patient is using chlorthalidone 25 mg daily and has a reported potassium level of 4.6 mEq/L. Which of the following statements is correct?

A. The patient needs an agent to lower her potassium level.
B. Chlorthalidone works by blocking Na+ reabsorption in the distal convoluted tubules.
C. Supplementation with prescription oral potassium is often required when thiazide diuretics are taken.
D. This is not an effective dose of chlorthalidone to lower BP.
E. Chlorthalidone has been shown to be less effective than other thiazide-type diuretics.

B. Patients can usually correct the mild potassium-lowering effect of thiazides by supplementing their diet with potassium-rich foods, including avocados, bananas and oranges.

Thiazide-type Diuretics: inhibit Na reabsorption in the distal convoluted tubules of nephron causing increase excretion of Na, water, K, H+. K-sparing diuretics also work here as well. SE: decrease (K, Mg, Na), increase (UA, LDL, TG, BG, Ca), rash dizziness, photosensitivity, pregnancy (B). Good for the bones unlike loop-diuretics which causes loss of Ca. Take early in the day to avoid nocturia. Do not work when CrCl

chlorthalidone (Thalitone): max 25mg/day (no BP benefit at higher doses), longest half life

hydrochlorothiazide (Microzide, Oretic): max 25-50mg/day (no BP benefit after 25mg)

chlorothiazide (Diuril): PO, IV, suspension

indapamide: data in stroke prevention

metolazone (Zaroxolyn): has additional MoA at proximal tubule

methyclothiazide:

23

A patient is using furosemide 20 mg QHS and has a reported potassium level of 2.9 mEq/L. Which of the following statements are correct regarding furosemide therapy? (Select ALL that apply.)

A. This medication can cause ototoxicity.
B. This medication is safe in patients with a severe sulfa allergy.
C. Furosemide should be taken in the morning, not at bedtime.
D. Potassium supplementation is often required when loop diuretics are taken.
E. The patient should be told to restrict calcium intake.

A, C, D. Loop diuretics are taken QAM or early enough in the day to prevent or reduce nocturia. Loop diuretics lower potassium, waste calcium and can cause ototoxicity. There is potential to cross-react with a sulfa allergy but this is rare.

24

A patient with diabetes, hypertension, and peptic ulcer disease is on aspirin, glyburide, enalapril, metoprolol, chlorthalidone, and famotidine. Which of the patient's medications may block signs and symptoms of hypoglycemia?

A. Enalapril
B. Metoprolol
C. Aspirin
D. Chlorthalidone
E. Famotidine

B. The physiologic response to hypoglycemia is mediated by sympathetic/adrenergic stimulation. Therefore, beta-blockers can mask many signs and symptoms of hypoglycemia.

Beta Blocking Agents: inhibit effects of catecholamines at beta-1 & beta-2 receptors to reduce BP and HR. Beta blockers with intrinsic sympathomimetic activity (ISA) partially stimulate beta receptors while blocking additional stimulation and are contraindicated in S/P MI patients. ISA agents are carteolol, acebutolol, penbutolol, pindolol (CAPP). Boxed warning: avoid abrupt withdrawal, must taper. CI: sinus bradycardia, 2nd or 3rd degree heart block, sick sinus syndrome, cardiogenic shock, active asthma exacerbation. Warning: caution in diabetes (hypoglycemia), asthma, severe COPD, Raynaud's disease, may mask hyperthryoidism, aggravate psychiatric conditions. SE: decrease HR, hypotension, fatigue, dizziness, depression, decrease libido, impotence, hyperglycemia, hypoglycemia, hypertriglyceridemia, decrease HDL, most pregnancy (C)

24

Alex, a 68 year old white male, is being treated at your clinic for hypertension. Today his BP is 147/93. His PMH is significant for GERD, diabetes and gout. Alex is currently taking Janumet XR, Motrin, Hyzaar and Zantac. Which of the following medications would be appropriate to add for better BP control according to JNC 8?

A. Hydrochlorothiazide
B. Procardia XL
C. Cardura
D. Coreg
E. Alex does not need additional BP lowering.

B. Alex is currently taking Hyzaar (losartan + HCTZ); therefore calcium channel blockers are the only other first line agents according to JNC 8 (since we cannot combine an ACE-I with an ARB).

JNC-8

Age 60 and up: BP goal

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

25

Charles presents to the emergency room after a motor vehicle accident. He is found to have a blood pressure of 192/112 mmHg. He has no acute organ damage and is diagnosed as having hypertensive urgency. Which of the following medications would not be an appropriate option to treat this condition:

A. Captopril
B. Nifedipine sublingual
C. Clonidine
D. Labetalol
E. Losartan

B. Sublingual nifedipine can cause an uncontrollable drop in blood pressure, which can result in myocardial infarction and other ischemic complications, hence should not be used.

26

Choose the correct statement regarding carvedilol to carvedilol CR dosing:

A. Carvedilol 25 mg BID is equivalent to Coreg CR 40 mg daily.
B. Carvedilol 6.25 mg BID is equivalent to Coreg CR 20 mg daily.
C. Carvedilol 12.5 mg BID is equivalent to Coreg CR 30 mg daily.
D. Carvedilol 3.125 mg BID is equivalent to Coreg CR 5 mg daily.
E. None of the above.

B. The starting dose of carvedilol immediate release is 3.125 mg BID for heart failure (equivalent to Coreg CR 10 mg), or 6.25 BID for hypertension (equivalent to Coreg CR 20 mg). The Coreg CR doses are 10 mg, 20 mg, 40 mg or 80 mg daily.

28

Choose the correct statements concerning Cleviprex: (Select ALL that apply.)

A. It comes in a milky white emulsion.
B. It is contraindicated in a soy or egg allergy.
C. It is an intravenous non-dihydropyridine calcium channel blocker.
D. The medication needs to be discarded after 4 hours of use.
E. The tubing for Cleviprex should be changed every 12 hours.

A, B, E. Cleviprex must be administered using strict aseptic technique and should be discarded 12 hours of use.

clevidipine (Cleviprex): IV, milky white emulsion provides 2kcal/mL, risk of infection & high TG, max hang time of 12 hours.

Calcium Channel Blockers (CCBs): 2 types (dihydropyridines [DHP] and non-DHPs).

DHPs: work in periphery causing peripheral vasodilation resulting in reflex tachycardia, flushing, HA, edema. Warning: angina/MI with initiation or titration, caution in aortic stenosis. SE: peripheral edema, fatigue, dizziness, headache, palpitation, flushing, tachycardia/reflex tachycardia, hypotension, gingival hyperplasia, pregnancy (C)

30

Frank comes to the clinic for a follow up visit for his hypertension and diabetes management. He has been taking four medications to control his blood pressure for a long time. Today, the pharmacist notices a butterfly rash across Frank's nose and upper cheeks. Which of the following medications is most likely to cause this side effect?

A. Hydrochlorothiazide
B. Enalapril
C. Hydralazine
D. Eplerenone
E. Verapamil

C. Hydralazine (Apresoline) can cause lupus-like syndrome which is dose and duration related.

hydrochlorothiazide (Microzide)

enalapril (Vasotec)

eplerenon (Inspra)

verapamil (Calan)

31

Jack is a white male patient who presents with high blood pressure on several visits. He works in construction. According to the JNC 8 guidelines, which class of medications are appropriate at initial therapy for Jack? (Select ALL that apply.)

A. Beta blockers
B. ACE inhibitors
C. Angiotensin receptor blockers
D. Calcium channel blockers
E. Thiazide-type diuretics

B, C, D, E. ACE inhibitors, ARBs, CCBs and thiazide-type diuretics can be used initially in this patient according to JNC 8.

JNC-8

Age 60 and up: BP goal

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

31

In 2012, a contraindication was added to the labeling of aliskiren. This contraindication warns not to use aliskiren in combination with ACE inhibitors or ARBs in patients with:

A. Diabetes
B. Hepatitis
C. Raynaud's syndrome
D. Myocardial infarction
E. Stroke

A.

Direct Renin Inhibitor (DRI):directly inhibits renen which is responsible for conversion of angiotensinogen to angiotensin I. Boxed warning: injury and death to developing fetus. CI: angioedema, do not use in bilateral renal artery stenosis, do not use with ACE-Is or ARBs in patients with diabetes. Warning: angioedema, avoid use with ACE-I or ARB, correct volume depletion prior to starting. SE: increase SCr and BUN, hyperkalemia, diarrhea, hypotension, pregnancy (D). metabolized by 3A4.

aliskiren (Tekturna): avoid high fat foods (decrease absorption)

32

Jackie presents to her doctor's office with hypertension. She is prescribed Lotrel. This medication contains:

A. Benazepril and amlodipine
B. Olmesartan and amlodipine
C. Valsartan and aliskiren
D. Valsartan and amlodipine
E. Irbesartan and hydrochlorothiazide

A. Lotrel contains benazepril and amlodipine.

33

Jackson has systolic heart failure with an ejection fraction of 33%. Which of the following medications could potentially worsen his heart failure condition?

A. Amlodipine
B. Verapamil
C. Ramipril
D. Labetalol
E. Candesartan

B. Verapamil and diltiazem are not used in systolic heart failure. Amlodipine and some of the other dihydropyridines are considered cardiac-neutral.

35

Jamal is a black male patient who presents with high blood pressure on several visits. He works as an attorney. According to the JNC 8 guidelines, which class of medications is appropriate at initial therapy for Jamal? (Select ALL that apply.)

A. Beta blockers
B. ACE inhibitors
C. Angiotensin receptor blockers
D. Calcium channel blockers
E. Thiazide-type diuretics

D, E. In black hypertensive patients, initial therapy should include a CCB or thiazide-type diuretic according to JNC 8.

JNC-8

Age 60 and up: BP goal

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

37

Jerry has hypertension that is difficult to control. He uses chlorthalidone, lisinopril, magnesium, amlodipine and clonidine daily. With this regimen, his blood pressure stays within the range of 122-144/84-98 mmHg. His heart rate averages 60 beats per minute (BPM). Jerry ran out of one of these medications last week. His blood pressure increased to 192/110 mmHg, with a heart rate of 90 BPM. Which of Jerry's medications would most likely cause this acute rise in blood pressure if suddenly discontinued?

A. Chlorthalidone
B. Lisinopril
C. Amlodipine
D. Clonidine
E. Magnesium

D. Clonidine causes rebound hypertension due to a sudden increase in sympathetic outflow. If discontinued, clonidine requires a slow taper to prevent this acute rise in blood pressure.

Centrally-Acting alpha-2 adrenergic agonist: stimulate alpha-2 in the brain resulting in reduced sympathetic outflow from CNS. CI: methyldopa only (active liver disease, concurrent use with MAO-I). SE: dry mouth, somnolence, headache, fatigue, dizziness, constipation, bradycardia hypotension, depression, behavioral changes, sexual dysfunction; patch (skin rash, pruritis, erythema, contact dermatitis). Methyldopa additional SE: hypersensitivity reactions, hepatitis, myocarditis, positive Coombs, drug-induced fever, drug-induced lupus erythematosus (DILE), can increase prolactin levels. Rebound hypertension if stopped abruptly, must taper. Pregnancy (B/C)

clonidine (Catapres, Duraclon inj): PO, patch, inj. patches Q weekly, remove patch before MRI. only form that comes as a patch in treating BP

guanfacine (Tenex) PO:

methyldopa: PO, inj

38

A patient is prescribed Inspra. What is the labeled indications for Inspra? (Select ALL that apply.)

A. Hypertension
B. Heart failure
C. Asthma
D. COPD
E. PAH

A, B. 

K-Sparing Diuretics: compete with aldosterone at the distal convoluted tubule and collecting ducts, increasing Na and water excretion while conserving K and H+. Not effective as monotherapy and are commonly used in combination. Boxed warning: tumor risk (spironolactone). CI: anuria, significant renal impairment, hyperkalemia. SE: hyperkalemia, increase SCr, dizziness, pregnancy (C)

spironolactone (Aldactone): for HTN and HF. blocks androgen (SE: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea), remember "A" for androgen block.

eplerenone (Inspra): for HTN and HF. selective aldosterone blocker (CI: when SCr >2 for males, >1.8 females, or CrCl

trimaterene (Dyrenium), triamterene/HCTZ (Maxzide, Dyazide):

amiloride (Midamor):

39

Loop diuretics, such as furosemide, work on this part of the nephron:

A. The proximal, convoluted tubule
B. The distal, convoluted tubule
C. The descending limb of the Loop of Henle
D. The ascending limb of the Loop of Henle
E. The afferent and efferent arterioles

D. Loop diuretics work on the ascending limb of the Loop of Henle. The thick ascending limb has a high Na+ reabsorptive capacity. By blocking sodium resorption, the loops have a potent diuretic effect Na+, Cl- and K+ excretion is increased.

41

Paula lives in Florida. She has been started on hydrochlorothiazide 25 mg daily. Which of the following statements are correct? (Select ALL that apply.)

A. She should use protective clothing and sunscreen while in the sun.
B. She has an increased risk for low bone density; calcium and vitamin D intake should be optimized.
C. She has an increased risk for hyperkalemia.
D. She has an increased risk for an allergic-type reaction.
E. Although she is not an at increased risk, this medication can cause dizziness, rash, and rarely hypochloremic alkalosis.

A, E. Loop diuretics (but not thiazides) increase the risk for low bone density. Thiazides, taken long-term, can modestly increase bone density. Thiazide and loop diuretics can make a person more sensitive to the sun; proper sunscreen and protective clothing should be encouraged.

Thiazide-type Diuretics: inhibit Na reabsorption in the distal convoluted tubules of nephron causing increase excretion of Na, water, K, H+. K-sparing diuretics also work here as well. SE: decrease (K, Mg, Na), increase (UA, LDL, TG, BG, Ca), rash dizziness, photosensitivity, pregnancy (B). Good for the bones unlike loop-diuretics which causes loss of Ca. Take early in the day to avoid nocturia. Do not work when CrCl

42

A patient gave the pharmacist a prescription for Dyazide 37.5-25 mg 1 tablet daily #30. Which of the following is an appropriate generic substitution for Dyazide?

A. Spironolactone and hydrochlorothiazide
B. Amiloride and hydrochlorothiazide
C. Triamterene and hydrochlorothiazide
D. Indapamide and hydrochlorothiazide
E. Azilsartan and chlorthalidone

C. Maxzide also contains triamterene with hydrochlorothiazide. Maxzide is 75-50 mg (the 50 mg HCTZ component is above the usual effective maximum for most patients and could contribute to low potassium or elevated blood glucose or uric acid) or Maxzide-25 which is 37.5-25 mg (same dose as Dyazide).

Thiazide-type Diuretics: inhibit Na reabsorption in the distal convoluted tubules of nephron causing increase excretion of Na, water, K, H+. K-sparing diuretics also work here as well. SE: decrease (K, Mg, Na), increase (UA, LDL, TG, BG, Ca), rash dizziness, photosensitivity, pregnancy (B). Good for the bones unlike loop-diuretics which causes loss of Ca. Take early in the day to avoid nocturia. Do not work when CrCl

chlorthalidone (Thalitone): max 25mg/day (no BP benefit at higher doses), longest half life

hydrochlorothiazide (Microzide, Oretic): max 25-50mg/day (no BP benefit after 25mg)

chlorothiazide (Diuril): PO, IV, suspension

indapamide: data in stroke prevention

metolazone (Zaroxolyn): has additional MoA at proximal tubule

methyclothiazide:

K-Sparing Diuretics: compete with aldosterone at the distal convoluted tubule and collecting ducts, increasing Na and water excretion while conserving K and H+. Not effective as monotherapy and are commonly used in combination. Boxed warning: tumor risk (spironolactone). CI: anuria, significant renal impairment, hyperkalemia. SE: hyperkalemia, increase SCr, dizziness, pregnancy (C)

spironolactone (Aldactone): for HTN and HF. blocks androgen (SE: gynecomastia, breast tenderness, impotence, irregular menses, amenorrhea), remember "A" for androgen block.

eplerenone (Inspra): for HTN and HF. selective aldosterone blocker (CI: when SCr >2 for males, >1.8 females, or CrCl

trimaterene (Dyrenium), triamterene/HCTZ (Maxzide, Dyazide):

amiloride (Midamor):

43

Thomas, a 48 year old white male, is being treated at your clinic for hypertension. Today his BP is 147/93. His PMH is significant for GERD, diabetes and gout. Thomas is currently taking Janumet XR, Motrin, Prinzide and Zantac. Which of the following medications would be appropriate to add for better BP control according to JNC 8? (Select ALL that apply.)

A. Cozaar
B. Altace
C. Adalat CC
D. Norvasc
E. Hydrochlorothiazide

C, D. Thomas is currently taking Prinzide (lisinopril + HCTZ); therefore calcium channel blockers are the only other first line agents according to JNC 8 (since we cannot combine an ACE-I with an ARB).

Cozaar (losartan)

Altace (ramipril)

Adalat CC (nifedipine)

Norvasc (amlodipine)

Age 60 and up: BP goal

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

44

What is the mechanism of action of clonidine?

A. Acts as an alpha-1 agonist, resulting in a decrease in norepinephrine release
B. Acts as an alpha-1 antagonist, resulting in an increase in norepinephrine release
C. Acts as an alpha-2 agonist, resulting in a decrease in norepinephrine release
D. Acts as an alpha-2 antagonist, resulting in a decrease in norepinephrine release
E. Acts as an alpha-1 and alpha-2 antagonist, resulting in an increase in norepinephrine release

C. By acting as an alpha-2 receptor agonist, norepinephrine outflow is reduced. This is called reducing sympathetic outflow.

Centrally-Acting alpha-2 adrenergic agonist: stimulate alpha-2 in the brain resulting in reduced sympathetic outflow from CNS. CI: methyldopa only (active liver disease, concurrent use with MAO-I). SE: dry mouth, somnolence, headache, fatigue, dizziness, constipation, bradycardia hypotension, depression, behavioral changes, sexual dysfunction; patch (skin rash, pruritis, erythema, contact dermatitis). Methyldopa additional SE: hypersensitivity reactions, hepatitis, myocarditis, positive Coombs, drug-induced fever, drug-induced lupus erythematosus (DILE), can increase prolactin levels. Rebound hypertension if stopped abruptly, must taper. Pregnancy (B/C)

clonidine (Catapres, Duraclon inj): PO, patch, inj. patches Q weekly, remove patch before MRI. only form that comes as a patch in treating BP

guanfacine (Tenex) PO:

methyldopa: PO, inj

45

What is the mechanism of action of Diovan?

A. Angiotensin-converting enzyme inhibitor
B. Beta1-selective adrenergic antagonist
C. Angiotensin receptor blocker
D. Calcium channel blocker
E. Alpha 2-receptor agonist

C. Diovan is an angiotensin receptor blocker.

Diovan (valsartan)

46

Which beta-blocker also confers alpha-1 receptor antagonistic activity?

A. Atenolol
B. Propranolol
C. Labetolol
D. Nebivolol
E. Esmolol

C. Beta-blockers which also have alpha-1 receptor blocking effects are more prone to causing orthostatic hypotension, but have fewer detrimental metabolic effects (insulin resistance, elevations in triglycerides).

atenolol (Tenormin)

propranolol (Inderal)

nebivolol (Bystolic)

Esmolol (Brevibloc)

Alpha-1 and non-selective beta blocker

labetalol (Trandate): PO, IV; used commonly in hospital

47

Which of the following agents is a beta-1 and beta-2 adrenergic antagonist that readily penetrates the CNS blood-brain barrier?

A. Metoprolol
B. Atenolol
C. Propranolol
D. Lisinopril
E. Amlodipine

C. Propranolol (Inderal LA, InnoPran XL) is a non-selective beta blocker and is highly lipophilic. It crosses the blood-brain barrier easily and has a higher incidence of CNS side effects, including fatigue and depression. It is used for migraine headache prophylaxis, essential tremor, stage fright, hypertension and a few other conditions.

Beta Blocking Agents: inhibit effects of catecholamines at beta-1 & beta-2 receptors to reduce BP and HR. Beta blockers with intrinsic sympathomimetic activity (ISA) partially stimulate beta receptors while blocking additional stimulation and are contraindicated in S/P MI patients. ISA agents are carteolol, acebutolol, penbutolol, pindolol (CAPP). Boxed warning: avoid abrupt withdrawal, must taper. CI: sinus bradycardia, 2nd or 3rd degree heart block, sick sinus syndrome, cardiogenic shock, active asthma exacerbation. Warning: caution in diabetes (hypoglycemia), asthma, severe COPD, Raynaud's disease, may mask hyperthryoidism, aggravate psychiatric conditions. SE: decrease HR, hypotension, fatigue, dizziness, depression, decrease libido, impotence, hyperglycemia, hypoglycemia, hypertriglyceridemia, decrease HDL, most pregnancy (C)

Beta-1 selective blockers: AMEBBA.

acebutolol (Sectral): PO

esmolol (Brevibloc): IV

atenolol (Tenormin): PO

betaxolol: PO

bisoprolol (Zebeta): PO

metoprolol tartrate (Lopressor), metoprolol succinate (Toprol XL): PO, IV. Lopressor with food. IV:PO ratio 1:2.5

Beta-1 blocker with nitric oxide-dependent vasodilation

nebivolol (Bystolic): PO. CI in severe liver impairment. caution with 2D inhibitors

Beta-1 & Beta-2 blockers (non-selective)

nadolol (Corgard): PO

penbutolol (Levatol): PO

pindolol: PO

propranolol (Inderal LA, InnoPran XL): PO, IV, solution; most lipophilic, more CNS side effects (sedation, depression, cognitive effects)

timolol: PO

Alpha-1 and non-selective beta blocker

labetalol (Trandate): PO, IV; used commonly in hospital

Non-selective alpha and beta blocker

carvedilol (Coreg): PO. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels

48

Which of the following antihypertensives should not be taken with grapefruit or grapefruit juice? (Select ALL that apply.)

A. Lopressor
B. Cardizem LA
C. Coreg
D. Calan SR
E. Dilt-XR

B, D, E. Counsel patients to avoid grapefruit (the juice and the fruit), or try an alternative drug that does not interact. Separating the time a person drinks or eats grapefruit from the drug will not work.

Avoid non-DHP CCBs:

non-DHP: negative inotrope and negative chronotrope, work peripherally and vasodilate coronary vasculature. both are 3A4 substrate and moderate 3A4 inhibitors. SE: edema, HA, dizziness, AV block, bradycardia, hypotension, arrhythmias, HF, constipation (more with verapamil), gingival hyperplasia, pregnancy (C). Avoid grapefruit juice.

diltiazem (Cardizem): PO, IV

verapamil (Calan): PO, IV requires protection from light during administration

49

Which of the following statements are true regarding enalapril? (Select ALL that apply.)

A. Enalapril can retain potassium; potassium levels must be monitored.
B. Enalapril is an angiotensin-converting enzyme inhibitor.
C. Enalapril comes in an oral and patch formulation.
D. Enalapril can cause a dry, hacking cough.
E. Enalapril has been shown to be beneficial in heart failure and renal protection in diabetes.

A, B, D, E. Enalapril does not come as a patch formulation.

Renin-Angiotensin Aldosterone System (RAAS) Inhibitors: ACE-I & ARB

First line in CKD, slow progression of kidney disease, HF, stroke. Do not use ACE-I and ARB together. Avoid in pregnancy (D), angioedema, bilateral renal artery stenosis, or with aliskiren in patients with DM or GFR

benazepril (Lotensin): PO

captopril (Capoten): PO, empty stomach

enalapril, enalaprilat IV (Vasotec): PO, IV, solution

lisinopril (Prinivil, Zestril): PO

moexipril (Univasc): PO, empty stomach

fosinopril (Monopril): PO

perindopril (Aceon): PO

quinapril (Accupril): PO

ramipril (Altace): PO

trandolapril (Mavik): PO

valsartan (Diovan): PO

losartan (Cozaar): PO

irbesartan (Avapro): PO

candesartan (Atacand): PO

olmesartan (Benicar): Sprue-like enteropathy (severe, chronic diarrhea with substantial weight loss) then stop Benicar

telmisartan (Micardis): PO

eprosartan (Teveten): PO

azilartan (Edarbi): PO, keep in original container

50

Roger has just been diagnosed with hypertension. His past medical history is significant for BPH and bilateral renal artery stenosis. Which of the following medications should not be used for treatment of his hypertension?

A. Calcium channel blockers
B. Angiotensin receptor blockers
C. Direct renin inhibitors
D. Angiotensin converting enzyme inhibitors
E. Beta-blockers

B, C, D. ACE inhibitors, ARBs, and the direct renin inhibitor (aliskiren) should not be used in patients with bilateral renal artery stenosis.

51

Which of the following antihypertensives can cause overgrowth of the gums with long-term use? (Select ALL that apply.)

A. Hydrochlorothiazide
B. Carvedilol
C. Diltiazem
D. Nifedipine
E. Propranolol

C, D. Calcium channel blockers can cause gingival hyperplasia, or overgrowth of the gums. Careful tooth cleaning and dental care are required to help preserve the patient's teeth.

52

Which of the following antihypertensives is associated with thiocyanate and cyanide toxicity with prolonged use?

A. Nitroprusside
B. Nitroglycerin
C. Esmolol
D. Hydralazine
E. Clevidipine

A. Nitroprusside is associated with both cyanide and thiocyanate toxicity.

53

Jermaine, a 63 year old black male, is a newly diagnosed with type 2 diabetes. He is also found to have hypertension, hypercholesterolemia, chronic kidney disease and peripheral arterial disease. Which of the following medications would be appropriate to start first-line for BP control according to JNC 8? (Select ALL that apply.)

A. Thiazide-type diuretics
B. ACE inhibitors
C. ARBs
D. Calcium channel blockers
E. Beta blockers

B, C. Patients with CKD should be started on an ACE inhibitor or ARB according to JNC 8.

JNC-8

Age 60 and up: BP goal <150/90. Age 18-59 or those with diabetes or CKD regardless of age: <140/90

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

54

Mr. Lopez, a 52 year old Mexican male, has hypertension and he is currently taking Lotrel. His BP today is 151/91. Which of the following medication recommendations would be in accordance with JNC 8? (Select ALL that apply.)

A. Change Lotrel to Exforge HCT
B. Change Lotrel to Amturnide
C. Add on hydrochlorothiazide
D. Add on valsartan
E. Change Lotrel to Azor

A, C. Lotrel contains a CCB + an ACEI. It would be appropriate to use Exforge HCT since this contains 3 drug classes initially recommended by JNC 8. Aliskiren is not recommended first-line and adding on an ARB to an ACE inhibitor is not recommended. Azor contains a CCB + ARB so this change would not provide better control his BP.

55

Which of the following side effects are associated with olmesartan? (Select ALL that apply.)

A. Cough
B. Angioedema
C. Diabetes
D. Sprue-like enteropathy
E. Hypokalemia

B, D. Sprue-like enteropathy is a new warning for olmesartan (2013).

Renin-Angiotensin Aldosterone System (RAAS) Inhibitors: ACE-I & ARB

First line in CKD, slow progression of kidney disease, HF, stroke. Do not use ACE-I and ARB together. Avoid in pregnancy (D), angioedema, bilateral renal artery stenosis, or with aliskiren in patients with DM or GFR <60. SE: hyperkalemia, hypotension, cough (ACE-I only), dizziness, headache. Can decrease lithium's renal clearance and increase risk of toxicity.

benazepril (Lotensin): PO

captopril (Capoten): PO, empty stomach

enalapril, enalaprilat IV (Vasotec): PO, IV, solution

lisinopril (Prinivil, Zestril): PO

moexipril (Univasc): PO, empty stomach

fosinopril (Monopril): PO

perindopril (Aceon): PO

quinapril (Accupril): PO

ramipril (Altace): PO

trandolapril (Mavik): PO

valsartan (Diovan): PO

losartan (Cozaar): PO

irbesartan (Avapro): PO

candesartan (Atacand): PO

olmesartan (Benicar): Sprue-like enteropathy (severe, chronic diarrhea with substantial weight loss) then stop Benicar

telmisartan (Micardis): PO

eprosartan (Teveten): PO

azilartan (Edarbi): PO, keep in original container

56

Jose has hypertension. He states he feels fine and cannot believe he has to take medicine. But, because the doctor told him to, he began to take lisinopril 10 mg daily. He developed an irritating, dry cough and was switched to irbesartan. He took the irbesartan for awhile then stopped using it. Which of the following factors can contribute to poor medication adherence in patients with hypertension? (Select ALL that apply.)

A. Lack of understanding of the need to take medicine
B. Inability to afford the medicine
C. Side effects
D. Hypertension is asymptomatic; therefore, the patient does not experience any symptom relief.
E. Patient does not believe in taking medicines

57

A patient has a severe sulfa allergy but needs to be started on an antihypertensive. Which of the following agents would be safest for this patient?

A. Furosemide
B. Bumetanide
C. Ethacrynic Acid
D. Metolazone
E. Hydrochlorothiazide

C. Ethacrynic acid is safe to use in patients with a sulfa allergy as it will not cross-react.

58

Derek has a BP of 220/110 and has new elevations in SCr and BUN at his clinic visit today. Which of the following statements regarding treatment of Derek's hypertensive emergency are correct? (Select ALL that apply.)

A. Derek has hypertensive emergency since he has a BP greater than 180/110-120 mmHg
B. Derek requires hospitalization for treatment with intravenous antihypertensive medication
C. Derek has hypertensive emergency since he has new onset renal impairment and a BP greater than 180/110-120 mmHg
D. Derek's BP should be reduced to a SBP range of 195-170 mmHg in the first hour
E. Derek's BP should be reduced to a SBP of < 140 mmHg in the first hour

B, C, D. Hypertensive emergencies are severe elevations in blood pressure complicated by clinical evidence of acute, progressive target organ dysfunction. Patients require intravenous medication to control their blood pressure and to prevent or limit further target organ damage. It is important to gradually lower the patient's blood pressure. A large reduction in BP can precipitate ischemia in these patients.

59

Asia is being discharged from the hospital. She was receiving 40 mg of furosemide IV per day. What is the equivalent oral dose of furosemide?

A. 20 mg
B. 40 mg
C. 60 mg
D. 80 mg
E. 120 mg

D.

IV:PO is 1:2

60

Jennifer suffers from constipation. She spends a good deal of money buying over-the-counter MiraLax and occasionally needs to use a glycerin suppository. She asks the pharmacist for help. The pharmacist looks at her medications and finds that she takes ramipril, lovastatin, cholestyramine, clonidine, verapamil and sertraline. Which medication/s could be contributing to Jennifer's chronic constipation? (Select ALL that apply.)

A. Clonidine
B. Sertraline
C. Cholestyramine
D. Lovastatin
E. Verapamil

A, C, E. Clonidine, cholestyramine and verapamil are constipating.

non-DHP: negative inotrope and negative chronotrope, work peripherally and vasodilate coronary vasculature. both are 3A4 substrate and moderate 3A4 inhibitors. SE: edema, HA, dizziness, AV block, bradycardia, hypotension, arrhythmias, HF, constipation (more with verapamil), gingival hyperplasia, pregnancy (C). Avoid grapefruit juice.

Centrally-Acting alpha-2 adrenergic agonist: stimulate alpha-2 in the brain resulting in reduced sympathetic outflow from CNS. CI: methyldopa only (active liver disease, concurrent use with MAO-I). SE: dry mouth, somnolence, headache, fatigue, dizziness, constipation, bradycardia hypotension, depression, behavioral changes, sexual dysfunction; patch (skin rash, pruritis, erythema, contact dermatitis). 

61

A patient with a history of hypertension and dyslipidemia is prescribed hydrochlorothiazide, enalapril, simvastatin, and niacin. The patient returns one month later complaining of pain and inflammation of his right toe. What combination of his medications could be causing this adverse effect?

A. Hydrochlorothiazide and enalapril
B. Enalapril and simvastatin
C. Niacin and simvastatin
D. Niacin and hydrochlorothiazide
E. Hydrochlorothiazide and simvastatin

D. The patient is experiencing an acute gouty attack of his right toe. Gout is caused by an increase in uric acid. Both hydrochlorothiazide (thiazide-type diuretics) and niacin can cause elevations in serum uric acid levels.

Thiazide-type Diuretics: inhibit Na reabsorption in the distal convoluted tubules of nephron causing increase excretion of Na, water, K, H+. K-sparing diuretics also work here as well. SE: decrease (K, Mg, Na), increase (UA, LDL, TG, BG, Ca), rash dizziness, photosensitivity, pregnancy (B). Good for the bones unlike loop-diuretics which causes loss of Ca. Take early in the day to avoid nocturia. Do not work when CrCl <30.

62

Sandra has end-stage renal disease secondary to lupus and hypertension. Her daily medications include atenolol, alendronate, prednisone, ranitidine, calcium and vitamin D. She uses Epogen as-directed. Which of Sandra’s medications can worsen her blood pressure control? (Select ALL that apply.)

A. Prednisone
B. Epogen
C. Alendronate
D. Atenolol
E. Ranitidine

A, B. Many agents can increase BP including prednisone and Epogen.

Drugs that worsen hypertension: ACTH, alcohol (excessive), amphetamines, appetite suppressants, caffeine, calcineurin inhibitors, corticosteroids, decongestants, erythropoiesis stimulating agents, estrogen, herbals (bitter orange, ephedra, ginseng, guarana, St. John's wort), mirabegron (Myrbetriq), NSAIDs, SNRIs at high doses, thyroid hormone, oncology drugs

63

Which of the following statements regarding hypertensive urgency are correct? (Select ALL that apply.)

A. Blood pressure greater than 180/110-120 mmHg
B. Requires hospitalization for treatment with intravenous medication
C. 2 antihypertensive medications should be started simultaneously
D. Absence of acute end organ dysfunction
E. Acute, progressive end organ dysfunction is present

A, D. Hypertensive urgencies are marked elevations in BP without acute end organ damage (although organ damage may be present). Management consists of oral agents. Follow-up with a physician within 24 to 72 hours is recommended.

64

A patient presents to the emergency department with a crushing headache and blurry vision. The patient's blood pressure is 230/128 mmHg, heart rate is 122 BPM. How rapidly should the blood pressure be reduced?

A. 5-10% in the next 4-6 hours
B. 10-15% in the next hour
C. 25-30% in the next 5 minutes
D. 40% by the next day
E. 50% in the next hour

B. The patient is experiencing a hypertensive emergency. Blood pressure in these situations should be reduced by no more than 25% within minutes to an hour. Too rapid of a reduction in BP can lead to ischemic complications. Too slow of a reduction in BP can lead to further end organ damage. The BP should be lowered in a controllable manner.

65

Randi presents to the emergency department with chest pain and shortness of breath. Randi's blood pressure is 195/115 mmHg, heart rate is 102 BPM and he is found to be having an acute myocardial infarction. Which of the following agents is most appropriate for lowering Randi's blood pressure?

A. Fenoldopam IV
B. Hydralazine IV
C. Captopril PO
D. Nitroglycerin IV
E. Metoprolol PO

D. The patient is experiencing a hypertensive emergency and should be treated with an intravenous antihypertensive agent. The drug of choice would be nitroglycerin which is an effective antihypertensive as well as an anti-ischemic agent.

66

A patient is receiving furosemide IV. Which of the following statements regarding furosemide IV is correct?

A. Furosemide is only compatible with NS
B. Furosemide is only compatible with D5W
C. Furosemide should be refrigerated once reconstituted in an IV bag
D. Refrigeration causes crystals to form
E. The IV:PO ratio is 1:2

D, E.

67

Which medication is considered first-line for the treatment of hypertension in pregnancy?

A. Atenolol
B. Spironolactone
C. Irbesartan
D. Diltiazam
E. Labetalol

E. Labetolol is one of the medications used first-line for hypertension in pregnancy.

Beta Blocking Agents: inhibit effects of catecholamines at beta-1 & beta-2 receptors to reduce BP and HR. Beta blockers with intrinsic sympathomimetic activity (ISA) partially stimulate beta receptors while blocking additional stimulation and are contraindicated in S/P MI patients. ISA agents are carteolol, acebutolol, penbutolol, pindolol (CAPP). Boxed warning: avoid abrupt withdrawal, must taper. CI: sinus bradycardia, 2nd or 3rd degree heart block, sick sinus syndrome, cardiogenic shock, active asthma exacerbation. Warning: caution in diabetes (hypoglycemia), asthma, severe COPD, Raynaud's disease, may mask hyperthryoidism, aggravate psychiatric conditions. SE: decrease HR, hypotension, fatigue, dizziness, depression, decrease libido, impotence, hyperglycemia, hypoglycemia, hypertriglyceridemia, decrease HDL, most pregnancy (C)

Beta-1 selective blockers: AMEBBA.

acebutolol (Sectral): PO

esmolol (Brevibloc): IV

atenolol (Tenormin): PO

betaxolol: PO

bisoprolol (Zebeta): PO

metoprolol tartrate (Lopressor), metoprolol succinate (Toprol XL): PO, IV. Lopressor with food. IV:PO ratio 1:2.5

Beta-1 blocker with nitric oxide-dependent vasodilation

nebivolol (Bystolic): PO. CI in severe liver impairment. caution with 2D inhibitors

Beta-1 & Beta-2 blockers (non-selective)

nadolol (Corgard): PO

penbutolol (Levatol): PO

pindolol: PO

propranolol (Inderal LA, InnoPran XL): PO, IV, solution; most lipophilic, more CNS side effects (sedation, depression, cognitive effects)

timolol: PO

Alpha-1 and non-selective beta blocker

labetalol (Trandate): PO, IV; used commonly in hospital

Non-selective alpha and beta blocker

carvedilol (Coreg): PO. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels

68

Which of the following medications are direct vasodilators? (Select ALL that apply).

A. Labetalol
B. Hydralazine
C. Minoxidil
D. Methyldopa
E. Doxazosin

B, C. Hydralazine and minoxidil are direct vasodilators. All others have indirect mechanisms.

Direct vasodilators: direct vasodilation of arterioles with little effect on veins causing a decrease in systemic vascular resistance and reduction in BP

hydralazine (Apresoline): PO, inj. Warning: drug-induced lupus erythematosus (DILE). SE: headache, reflex tachycardia, palpitation

minoxidil: PO. SE: fluid retention, tachycardia, aggravation of angina, pericardial effusion, hair growth

69

What is the brand name of metoprolol succinate?

A. Lopressor
B. Toprol XL
C. Sectral
D. Zebeta
E. Dutoprol

B. The brand name for metoprolol succinate is Toprol XL.

Lopressor (metoprolol tartrate)

Sectral (acebutolol)

Zebeta (bisoprolol)

70

Jermaine, a 63 year old black male, has a past medical history significant for type 2 diabetes, hypertension, hypercholesterolemia, chronic kidney disease and peripheral arterial disease. What is Jermaine's goal BP according to JNC 8?

A. Less than 120/80 mmHg
B. Less than 130/80 mmHg
C. Less than 140/80 mmHg
D. Less than 140/90 mmHg
E. Less than 150/90 mmHg

D. Goal BP for patients with chronic kidney disease is < 140/90, regardless of age.

JNC-8

Age 60 and up: BP goal <150/90. Age 18-59 or those with diabetes or CKD regardless of age: <140/90

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

71

Benice is a 71 year old African-American female with hypertension. Her last BP reading was 165/101mmHg and she is willing to be started on medication. According to JNC 8, which of the following statements are correct for treating Benice? (Select ALL that apply.)

A. Benice should be started on either an ACE inhibitor, ARB, CCB and/or thiazide-type diuretic
B. Benice should be started on either a CCB and/or thiazide-type diuretic.
C. Benice should be treated to a goal BP of < 150/90 mmHg
D. Benice should be treated to a goal BP of < 140/90
E. Benice can be started on 2 medications initially

B, C, E. Benice should be treated to a goal BP of < 150/90 mmHg using thiazide-type diuretics or CCB, alone or in combination.

JNC-8

Age 60 and up: BP goal <150/90. Age 18-59 or those with diabetes or CKD regardless of age: <140/90

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

72

Which of the following organizations sets the guidelines for the management of hypertension?

A. The American Society of Hypertension Physicians
B. Society for Vascular Medicine
C. The Joint National Committee
D. The Judicial Nominating Commission
E. The Joint National Commission

C.

73

Diltiazem and verapamil affect the hepatic metabolism of other drugs. This is due to the following reason:

A. They are CYP 450 3A4 inducers.
B. They are CYP 450 3A4 inhibitors.
C. They are CYP 450 2D6 inducers.
D. They are CYP 450 2C9 inducers.
E. They are CYP 450 2C19 inhibitors.

B. These drugs are 3A4 enzyme inhibitors and can raise the concentration of 3A4 substrates.

non-DHP: negative inotrope and negative chronotrope, work peripherally and vasodilate coronary vasculature. both are 3A4 substrate and moderate 3A4 inhibitors. SE: edema, HA, dizziness, AV block, bradycardia, hypotension, arrhythmias, HF, constipation (more with verapamil), gingival hyperplasia, pregnancy (C). Avoid grapefruit juice.

diltiazem (Cardizem): PO, IV

verapamil (Calan): PO, IV requires protection from light during administration

74

A cardiologist has ordered nebivolol 5 mg PO daily for Mr. Smith. What is the mechanism of action of nebivolol? (Select ALLthat apply.)

A. Inhibitor of beta1- and 2-adrenergic receptors
B. Inhibitor of beta1-adrenergic receptors
C. Produces nitric oxide-dependent vasodilation
D. Inhibitor of alpha1 and alpha2-adrenergic receptors
E. Inhibitor of alpha1-adrenergic receptors

B, C. 

Beta Blocking Agents: inhibit effects of catecholamines at beta-1 & beta-2 receptors to reduce BP and HR. Beta blockers with intrinsic sympathomimetic activity (ISA) partially stimulate beta receptors while blocking additional stimulation and are contraindicated in S/P MI patients. ISA agents are carteolol, acebutolol, penbutolol, pindolol (CAPP). Boxed warning: avoid abrupt withdrawal, must taper. CI: sinus bradycardia, 2nd or 3rd degree heart block, sick sinus syndrome, cardiogenic shock, active asthma exacerbation. Warning: caution in diabetes (hypoglycemia), asthma, severe COPD, Raynaud's disease, may mask hyperthryoidism, aggravate psychiatric conditions. SE: decrease HR, hypotension, fatigue, dizziness, depression, decrease libido, impotence, hyperglycemia, hypoglycemia, hypertriglyceridemia, decrease HDL, most pregnancy (C)

Beta-1 selective blockers: AMEBBA.

acebutolol (Sectral): PO

esmolol (Brevibloc): IV

atenolol (Tenormin): PO

betaxolol: PO

bisoprolol (Zebeta): PO

metoprolol tartrate (Lopressor), metoprolol succinate (Toprol XL): PO, IV. Lopressor with food. IV:PO ratio 1:2.5

Beta-1 blocker with nitric oxide-dependent vasodilation

nebivolol (Bystolic): PO. CI in severe liver impairment. caution with 2D inhibitors

Beta-1 & Beta-2 blockers (non-selective)

nadolol (Corgard): PO

penbutolol (Levatol): PO

pindolol: PO

propranolol (Inderal LA, InnoPran XL): PO, IV, solution; most lipophilic, more CNS side effects (sedation, depression, cognitive effects)

timolol: PO

Alpha-1 and non-selective beta blocker

labetalol (Trandate): PO, IV; used commonly in hospital

Non-selective alpha and beta blocker

carvedilol (Coreg): PO. additional SE: weight gain, edema. 2D6 substrate. can increase digoxin & cyclosporin levels

75

Rose comes to the pharmacy for her refill of torsemide 10 mg daily. The pharmacy is currently out of stock on torsemide but has furosemide in stock. What is the equivalent dose of furosemide for Rose?

A. 10 mg/day
B. 20 mg/day
C. 40 mg/day
D. 80 mg/day
E. 100 mg/day

B. 10 mg of torsemide = 20 mg of furosemide

76

The intravenous drug of choice for a hypertensive patient with an aortic dissection is:

A. Nitroprusside
B. Nitroglycerin
C. Esmolol
D. Hydralazine
E. Clevidipine

C. Beta blockers are the drugs of choice for patients with aortic dissection. By reducing the blood pressure and heart rate, sheer forces that may cause the dissection to worsen will be lessened. Use of vasodilatory antihypertensives without concomitant beta blockade is contraindicated in patients with aortic dissection.

77

Martha, a 64 year old white female, has type 2 diabetes without any kidney impairment. What is Martha's goal blood pressure according to JNC 8?

A. <120/80 mmHg
B. <130/80 mmHg
C. <130/85 mmHg
D. <140/90 mmHg
E. <150/90 mmHg

D. Goal BP for patients with diabetes is < 140/90, regardless of age.

JNC-8

Age 60 and up: BP goal <150/90. Age 18-59 or those with diabetes or CKD regardless of age: <140/90

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

78

Which of the following medications should be taken with food? (Select ALL that apply.)

A. Carvedilol immediate-release
B. Metoprolol succinate
C. Metoprolol tartrate
D. Carvedilol extended-release
E. Valsartan

A, C, D. With carvedilol, both the IR and CR formulations, the drug is taken with food to slow down absorption in order to reduce dizziness. Metoprolol regular tablets should be taken with food. Metoprolol extended release tablets may be taken without regard to meals.

79

A patient has diabetes and microalbuminuria and a BP of 151/93 mmHg. The patient has no other co-morbid conditions. Which drug would be the first-line antihypertensive for this patient?

A. Losartan
B. Atenolol
C. Hydrochlorothiazide
D. Hydralazine
E. Amlodipine

A. ACE inhibitors and angiotensin receptor blockers should be used first-line in patients with chronic kidney disease.

JNC-8

Age 60 and up: BP goal <150/90. Age 18-59 or those with diabetes or CKD regardless of age: <140/90

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

80

Jay is a 62 year-old African American male. His potassium level is 4.2 mEq/L, sodium is 141 mEq/L, BUN is 24 mg/dL and his serum creatinine is 1.2 mg/dL. Jay’s current medications include atenolol and citalopram. The physician is considering starting fosinopril. Jay has a risk factor for developing angioedema. Which risk factor for angioedema is present in this patient?

A. Age
B. Gender
C. Ethnicity
D. Concurrent medications
E. Electrolyte profile

C. There is a higher incidence of angioedema in black patients. Counsel the patient to report any swelling of the lips, mouth, tongue, face, or neck immediately.

81

Sean, a 55 year old white male, has just been diagnosed with hypertension. He has no other known medical conditions. His blood pressure runs between 170-174/97-99 mmHg. Choose an appropriate initial treatment regimen for this patient according to JNC 8? (Select ALL that apply.)

A. Lisinopril-HCT
B. Amlodipine and benazepril
C. Lisinopril and irbesartan
D. Amlodipine and aliskiren
E. Hydrochlorothiazide and labetalol

A, B. Do not combine and ACE-I and ARB; beta blockers are not recommended first-line in JNC8.

JNC-8

Age 60 and up: BP goal <150/90. Age 18-59 or those with diabetes or CKD regardless of age: <140/90

Drug class recommendation for initial therapy: ACE-I (1st line for CKD), ARBs (1st line for CKD), CCBs (1st line in blacks), thiazide-type diuretics (1st line in blacks). All in addition to lifestyle modifications.

CKD over ethnicity: ACE-I or ARB. CKD is albuminuria >30mg of albumin/(g of creatinine)

No CKD, based on ethnicity: use CCB or thiazide in black patients. ACE-I, ARB, CCB, or thiazide in non-black patients.

If diabetes with no CKD, based on ethnicity: same as above.

82

A patient with hypertension has been prescribed isradipine. Which of the following are possible side effects from the use of isradipine? (Select ALL that apply.)

A. Peripheral edema
B. Flushing
C. Hypokalemia
D. Headache
E. Hyperuricemia

A, B, D. These side effects, along with reflex tachycardia, go together. Once the blood pools peripherally (which causes headache and flushing), the heart starts to pump faster (tachycardia) to push the blood back into the circulation. This is more common with the shorter-acting dihydropyridine calcium channel blockers, but is occasionally seen with longer-acting formulations.

Calcium Channel Blockers (CCBs): 2 types (dihydropyridines [DHP] and non-DHPs).

DHPs: work in periphery causing peripheral vasodilation resulting in reflex tachycardia, flushing, HA, edema. Warning: angina/MI with initiation or titration, caution in aortic stenosis. SE: peripheral edema, fatigue, dizziness, headache, palpitation, flushing, tachycardia/reflex tachycardia, hypotension, gingival hyperplasia, pregnancy (C)

Decks in Pharmacy Class (61):