HTN Treatment Updates Flashcards
ACEI, ARB, direct renin inhibitor (DRI) interactions
Aliskiren in Type 2 Diabetes Using Cardio–Renal Endpoints (ALTITUDE) trial: Patients with diabetic kidney disease receiving combination therapy with aliskiren and either an ACEI or ARB had reduced proteinuria and SBP by 1 to 2 mm Hg compared with those receiving lone ACEI or ARB therapy at the expense of 25% greater stroke rate and more frequent hyperkalemia.
Over suppression of RAAS leads to worse outcome.
Body mass index: Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic HTN (ACCOMPLISH) trial:
ACCOMPLISH trial suggests the preferential addition of a CCB over a diuretic to an ACEI in the treatment of HTN in normal-weight patients for improved cardiovascular benefits. In obese high-risk hypertensive patients, however, the choice of adding either a diuretic versus CCB to an ACEI is less important.
Body mass index: Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic HTN (ACCOMPLISH) trial:
Proposed mechanism for observed difference: Compared to obese patients, lean individuals are thought to have more prominent RAAS and SNS activities. The use of diuretic in lean patients could further stimulate RAAS and lead to worse cardiovascular outcomes.
Renal denervation for resistant HTN:
Simplicity HTN-3 trial: no benefit
Concerns regarding procedure:
May promote renal artery atherogenesis
Interference with denervated kidney ability to tolerate insults such as volume depletion, infection, trauma, drug exposures.
Chlorthalidone (CTD) versus hydrochlorothiazide (HCTZ):
Longer half-life: CTD (~40 hours) versus HCTZ (~4 hours)]
Chlorthalidone is associated with lower LDL and glucose levels
Meta-analysis: 19% lower cardiovascular event rate for CTD compared with HCTZ.
Better nighttime BP control. Other beneficial non-BP related effects may be possible.
Orthostatic hypotension management:
Goal: focus on the well-being of patient, not achieving a specific BP level
Nondrug: increase fluid and salt intake, avoid getting up quickly or prolonged motionless standing, use of compressive waist-high stockings, raise head of be by 6 to 9 inches, maintain active lifestyle.
Drug options: midodrine, fludrocortisone, and pseudoephedrine
If supine HTN: consider midodrine as needed basis (prn).
If no supine HTN: consider fludrocortisone or midodrine prn. Combination therapy if necessary.
Sodium glucose transporter-2 (SGLT-2):
canagliflozin (Invokana)
empagliflozin (Jardiance)
empagliflozin/linagliptin (Glyxambi)
empagliflozin/metformin (Synjardy)
Expressed in S1 and S2 segments of proximal renal tubule where 90% of glucose reabsorption occurs]
Inhibition of SGLT-2 leads to glucosuria, hence glucose control in diabetics, and weight loss due to glucose-derived calories.
Inhibition of SGLT-2 also leads to mild BP reduction, presumably via (osmotic) diuretic effect.
SGLT2 is a protein in humans that facilitates glucose reabsorption in the kidney. SGLT2 inhibitors block the reabsorption of glucose in the kidney, increase glucose excretion, and lower blood glucose levels.
There is also an increased desire to urinate and the medication is not indicated in patients with type 1 diabetes, or patients with frequent ketones in their blood or urine, severe renal impairment, end stage renal disease or patients receiving dialysis.
