Hypertensives Flashcards
(258 cards)
1
Q
Angiotensin II causes _________ and __________ leading to retention of _________
A
vasoconstriction
&
increased release of aldosterone
Na+ and H2O
2
Q
RAAS inhibitors decrease blood pressure by _________
A
inhibiting the effects of Angiotensin II
3
Q
What classes of drugs have shown to slow the progression of kidney disease in patients with albuminuria?
A
ACE inhibitors and ARBs
4
Q
Angiotensin II constricts the ____________ of the nephron, causing increased workload in the glomeruli; which over time, results in _________
A
efferent arterioles
kidney damage
5
Q
In heart failure, ACE inhibitors and ARBs protect the myocardium from what?
A
remodeling effects of Angiotensin II
6
Q
RAAS inhibitors should NOT be used in combination due to increased risk of _________
A
adverse effects
7
Q
RAAS inhibitors include _____
A
ACE inhibitors, ARBs, aliskiren, ARNI
8
Q
What is a potentially fatal adverse effect that can occur with the use of any RAAS inhibitor? Who is at higher risk?
A
Angioedema: the swelling of the deeper layers of the skin caused by a build up of fluid.
More common with ACE inhibitors than ARBs or aliskiren
black patients
9
Q
If a patient develops angioedema with any RAAS inhibitor then __________
A
all other RAAS inhibitors SHOULD BE AVOIDED
10
Q
What class of drugs blocks the conversion of Angiotensin I to Angiotensin II? and what is the result?
A
ACE Inhibitors
decrease in vasoconstriction and decrease in aldosterone secretion
they also block the degradation of bradykinin, which is thought to contribute to vasodilatory effects and side effects of dry /hacking cough & angioedema.
11
Q
What class of drugs blocks the degradation of bradykinin?
A
ACE inhibitors,
this is thought to contribute to the vasodilatory effects & side effects of a dry/hacking cough and angioedema
12
Q
Lotensin *
A
benazepril
13
Q
Vasotec *
A
enalapril
14
Q
Vasotec IV *
A
enalaprilat
15
Q
Prinivil *
A
lisinopril
16
Q
Zestril *
A
lisinopril
17
Q
Qbrelis
A
lisinopril oral solution
18
Q
Accupril *
A
quinapril
19
Q
Altace *
A
ramipril
20
Q
Uncontrolled Hypertension places the patient at greater risk for ________
A
heart disease, stroke and kidney disease
21
Q
Most patients have ________ hypertension. The cause is unknown.
A
primary or essential hypertension
22
Q
secondary hypertension can be caused by _____________
A
renal disease (chronic kidney disease), adrenal disease, obstructive sleep apnea, or drugs
23
Q
___________ is responsible for the conversion of angiotensinogen to angiotensin I
A
Renin
24
Q
________ directly inhibits renin preventing the conversion of angiotensinogen to angiotensin I
A
Renin Inhibitor
25
Angiotensinogen is released by the _______
liver
26
Renin is released by the ______
kidneys
27
BP assessments should be based on an average of at least ____________readings on _________, preferably standardized to the timing of medication administration
2 readings
2 separate occasions
28
The ACC/AHA has defined 4 categories of blood pressure in adults:
normal blood pressure: SBP < 120mmHg AND DBP < 80mmHg
elevated BP: SBP 120-129mmHg AND DBP < 80mmHg
Stage 1 HTN: SBP 130-139mmHg oorrr DBP 80-89
Stage 2 HTN: SBP >= 140mmHg oorrr DBP >= 90mmHg
29
normal blood pressure =
SBP < 120mmHg AND DBP < 80mmHg
30
elevated blood pressure =
SBP 120-129mmHg AND DBP < 80mmHg
31
Stage 1 HTN =
SBP 130-139mmHg ooorrrrr DBP 80-89mmHg
32
Stage 2 HTN =
SBP >= 140mmHg ooorrrr DBP >= 90mmHg
33
Lifestyle interventions are essential to prevent hypertension. Proven interventions include:
Weight loss (1kg of weight loss decreases BP by ~1 mmHg)
heart healthy diet [DASH eating plan (Dietary Approaches to Stop Hypertension] that is high in fruits, vegetables, fiber and low fat dairy products
Reduce sodium intake to < 1500mg daily
Routine physical activity
Limiting alcohol consumption to one drink daily for women and two drinks daily for men
Tobacco cessation
controlling blood glucose and cholesterol to reduce cardiovascular disease risk
34
What is the correct way to use Blood pressure monitor?
first go to restroom and empty bladder
Sit in a chair (both feet on the floor) and relax for at least 5 minutes
Use the correct cuff size
Support the arm at heart level (resting on a desk)
Wait 1-2 minutes in between measurements
35
What Not to do when using a blood pressure monitor?
DON'T
talk
sit or lie down on the examination table
drink caffeine, exercise or smoke for 30 minutes prior
Use a finger or wrist monitor (less accurate)
36
Key Drugs that can increase Blood Pressure
Amphetamines
Cocaine
Decongestants (pseudoephedrine, phenylephrine)
Erythropoiesis-stimulating agents
Immunosuppressants (cyclosporine)
NSAIDs
Systemic steroids
37
What are some natural products that can reduce blood pressure?
Although not recommended by guidelines: Fish oil, coenzyme Q10, L-arginine, and garlic have some evidence for reducing blood pressure and overall cardiovascular risk.
38
What are the four preferred drug classes for Tx hypertension?
Ace inhibitors
ARBs
thiazides
(DHP) dihydropyridine calcium channel blockers
39
When do we start Treatment for Hypertension in patients?
If patients have:
Stage 2 Hypertension
or
Stage 1 Hypertension AND 1 of the following:
1) clinical CVD (stroke, heart failure, or coronary heart
disease)
2) 10 year ASCVD risk >= 10%
3) Does not meet Blood pressure goals after 6 months of
lifestyle modifications
40
What is Blood Pressure Goal?
All patients < 130/80 mmHg
41
Initial drug selection for hypertension in patients that are:
Non-black
thiazides, DHP CCBs, ACE inhibitors, or ARBs
42
Initial drug selection for hypertension in patients that are:
Black
thiazide or DHP CCBs
43
Initial drug selection for hypertension in patients that have CKD*** (all races):
ACE inhibitor or ARB (to slow the progression to ESRD)
***CKD: stage 3 (eGFR < 60mL/min/m^2) and/or albuminuria (urine albumin >= 300mg/day or albumin: creatinine ratio >= 300mg/g)
44
Initial drug selection for hypertension in patients that have Diabetes with albuminuria (all races):
ACE inhibitor or ARB
45
Initial drug selection for hypertension in patients that have Diabetes with CAD*** (all races):
Ace inhibitor or ARB
46
When do we start 2 first-line drugs (from preferred drug classes) in Stage 2 hypertension?
If SBP and DBP are > 20/10 mmHg above goal
ex. 150/90mmHg
47
The ADA recommends a goal BP of ___________ for patients with diabetes and high ASCVD risk, and __________ for patients at lower risk
< 130/80 mmHg
< 140/90 mmHg
48
The 2021 KDIGO guidelines recommend a goal SBP __________ for patients with hypertension and CKD
< 120 mmHg
49
which hypertension drugs have Boxed warnings for Fetal toxicity in pregnancy and should be stopped immediately?
ACE inhibitors
ARBs
aliskiren
50
Antihypertensive drugs can be used in pregnancy to Tx?
preeclampsia
gestational hypertension ( hypertension that develops during pregnancy)
chronic hypertension ( hypertension before pregnancy)
51
Preeclampsia occurs after ___________of the pregnancy and is evident by elevated blood pressure and proteinuria in the majority of cases
week 20
52
Preeclampsia
a serious blood pressure condition that develops during pregnancy, having high blood pressure and high levels of protein in their urine
53
Pregnant patients with chronic hypertension (hypertension before pregnancy) should receive treatment if ________
SBP >= 160mmHg or DBP >= 105mmHg
54
In patients at high risk of preeclampsia, a __________ is recommended after the first trimester
daily low aspirin
55
The American College of Obstetricians and Gynecologists recommend ________ and _________ as first line treatments. _________ is also recommended but may be less effective at lowering BP.
labetalol (Trandate, Normodyne)
nifedipine extended release (Procardia XL, )
methyldopa (Aldomet)
56
Pregnant patients with chronic hypertension should have a blood pressure maintained between __________
120-160 mmHg SBP AND 80-110 mmHg DBP
57
Zestoretic *
Lisinopril/hydrochlorothiazide
58
Lotrel *
benazepril/amlodipine
59
Maxzide *
Triamterene/HCTZ
60
Hyzaar *
losartan/HCTZ
61
Exforge *
valsartan/amlodipine
62
Dyazide *
triamterene/HCTZ
63
Benicar HCT *
olmesartan/HCTZ
64
Diovan HCT *
valsartan/HCTZ
65
Tenoretic *
atenolol/chlorthalidone
66
Ziac *
bisoprolol/HCTZ
67
Edarbyclor
azilsartan/chlorthalidone
68
Lotensin HCT
benazepril/HCTZ
69
Vaseretic
enalapril/HCTZ
70
Avalide
irbesartan/HCTZ
71
Micardis HCT
telmisartan/HCTZ
72
Tribenzor
olmesartan/amlodipine/hydrochlorothiazide
73
Azor
olmesartan/amlodipine
74
Twynsta
telmisartan/amlodipine
75
Tekturna HCT
aliskiren/HCTZ
76
Lopressor HCT
metoprolol tartrate/HCTZ
77
Dutoprol
metoprolol succinate/HCTZ
78
Exforge HCT
valsartan/amlodipine/HCTZ
79
Aldactazide
spironolactone/HCTZ
80
Thiazide-type diuretics inhibit __________ reabsorption in the __________. This causes increased excretion of ____________
Na+
distal convoluted tubules of the nephrons
Na+ , Cl- , H2O , K ( sodium, chloride, water, potassium)
81
Microzide *
hydrochlorothiazide
82
Diuril
chlorothiazide
83
Mykrox
metolazone (thiazide type diuretic)
84
Lozol
indapamide (thiazide type diuretic)
85
Thiazide-Type Drug interactions
Drugs that can cause sodium and water retention can decrease the effectiveness of antihypertensives. (Do not use in combination)
ex. NSAIDs
86
Thiazide diuretics and lithium DDI
thiazide diuretics can decrease lithium renal clearance and increase the risk of lithium toxicity. Do not use in combination if possible.
87
Thiazide diuretics and dofetilide DDI
thiazide diuretics can increase dofetilide serum concentrations leading to an increase risk of QT prolongation; do not use in combination
88
Thalitone *
chlorthalidone (thiazide type diuretic)
89
what are the contraindications for thiazide type diuretics?
Hypersensitivity to Sulfonamide-derived drugs (not likely to cross react), anuria (failure of the kidneys to produce urine)
90
There is increased excretion of electrolytes _______ with the use of thiazide type diuretics
Na, Mg, K,
91
Thiazide diuretics are not effective when ___________, except for ______
CrCl < 30ml/min, metolazone
92
Which thiazide type diuretic is the only one available in a IV formulation?
chlorothiazide
93
thiazide type diuretics, should be taken early in the morning to avoid ________
nocturia (get up at night to use bathroom)
94
DHP CCBs (dihydropyridine calcium channel blockers) are used for: __________
hypertension, chronic stable angina, and Prinzmetal's angina
95
Prinzmetal's angina:
a known clinical condition characterized by chest discomfort or pain at rest with transient electrocardiograph changes in the ST segment, and with a prompt response to nitrates
96
MOA of DHP CCBs -
they inhibit Ca++ ions from entering vascular smooth muscle and myocardial cells, this causes peripheral arterial vasodilation "which decreases SVR and BP" (systemic vascular resistance and blood pressure) and coronary artery vasodilation
97
Norvasc *
amlodipine
98
Katerzia
amlodipine oral suspension
99
Cardene IV *
nicardipine IV
100
Adalat CC *
nifedipine ER
101
Procardia XL *
nifedipine ER
102
Procardia
nifedipine IR
103
Sular
nisoldipine ER
104
Plendil
felodipine ER
105
Cleviprex
clevidipine
106
What is the Contraindication with the drug Nicardipine
Should NOT be used in advanced aortic stenosis
107
___________ is considered the safest if a CCB must be used to lower BP in heart failure with reduced ejection fraction
amlodipine
108
__________ is a drug of choice in pregnancy
Nifedipine ER
109
DHP CCBs (eg. nifedipine ER) are used to prevent peripheral vasoconstriction in __________
Raynaud's (cold/blue fingers)
110
Do NOT Use Nifedipine IR for _____________
chronic hypertension (hypertension before pregnancy) or acute blood pressure reduction in non-pregnant adults (profound hypotension, MI and/or death has occurred)
111
Side effects with DHP CCBs
generally well tolerated, peripheral edema/headache/flushing/palpitations/reflex tachycardia/fatigue (worse with nifedipine IR) nausea, gingival hyperplasia (more with non-DHP CCBs)
112
Which DHP CCBs have an OROS/gel matrix formulation and can leave a ghost tablet (empty shell) in stool
Adalat CC and Procardia XL: Nifedipine ER formulations
113
If patient has an allergy to soybeans, soy products or eggs, which CCB is contraindicated for the patient??
Cleviprex (clevidipine) - DHP CCB
114
Which DHP CCB comes as a lipid emulsion (providing 2 kcal/mL) and is a milky white in color?
Cleviprex (clevidipine)
115
What is the maximum time of use after vial puncture of Cleviprex?
12 hours
116
Propofol (_________) is another lipid emulsion that provides _________ kcal/mL and requires tubing and vial changes every 12 hours
Diprivan
1.1kcal/mL
117
The non-DHP CCBs include ________ and ________
verapamil and diltiazem
118
Primarily the non-DHP CCBs are used to ____________. Sometimes are used for ______
control HR in certain arrhythmias (atrial fibrillation)
hypertension and angina
119
MOA for non-DHP CCBs:
they inhibit Ca++ ions from entering vascular smooth muscle and myocardial cells, by blocking Ca++ channels, BUT are more selective for the myocardium than the DHP CCBs.
120
The decrease in blood pressure produced by non-DHP CCBs is due too ____________
negative inotropic (decrease force of ventricular contraction)
&
negative chronotropic (decrease heart rate) effects
121
Cardizem *
diltiazem
121
Tiazac *
diltiazem
122
Calan SR *
verapamil
123
Verelan
verapamil
124
what are the contraindications with diltiazem
1) patient has Sick Sinus Syndrome or a 2nd or 3rd degree AV block ---- Unless they have a functioning ventricular pacemaker
2) patient has severe hypotension ( less than 90 mmHg systolic) or cardiogenic shock
3) hypersensitivity to the drug
4) patient with acute myocardial infarction and pulmonary congestion
125
what are the contraindications with verapamil
1) atrial flutter or atrial fibrillation and an accessory by pass tract
2) severe left ventricular dysfunction
3) severe hypotension ( less than 90 mmHg systolic) or cardiogenic shock
4) patient has Sick Sinus Syndrome or a 2nd or 3rd degree AV block ---- Unless they have a functioning ventricular pacemaker
126
Non-DHP CCBs are used to _________
reduce rapid heart rate in atrial fibrillation
127
IV:PO conversions of non DHP CCBs ____
are NOT 1:1
128
side effects with non-DHP CCBs include _________
edema, constipation (more with verapamil) gingival hyperplasia
headache, dizziness
129
Warnings with using non-DHP CCBs include _________
Heart failure (may worsen symptoms), bradycardia, hypotension. increased LFTs
cardiac conduction abnormalities (diltiazem)
hypertrophic cardiomyopathy (verapamil)
130
All CCBs are major substrates of __________ except for _________. Do NOT use with ________
CYP450 3A4
clevidipine
grapefruit juice
131
diltiazem and verapamil are inhibitors of _________
P-gp and moderate inhibitors or CYP3A4
132
Patients who take statins should use lower doses of ________ and __________ or can use a statin that is NOT metabolized by CYP3A4 including __________
simvastatin or lovastatin
pitavastatin
pravastatin
rosuvastatin
133
With CCBs use caution with other drugs that decrease HR including: ____________
beta blockers, digoxin, clonidine, amiodarone
dexmedetomidine
134
What are the Boxed Warnings with ACE inhibitors?
Cause injury and death to the developing fetus when used in the 2nd and 3rd trimesters; Discontinue as soon as pregnancy is detected
135
What are the Contraindications with ACE inhibitors?
DO NOT Use with Hx of angioedema
DO NOT Use within 36 hours of Entresto
Do Not Use with aliskiren in diabetes
136
What are the Warnings with ACE inhibitors?
Angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (avoid use)
137
What are the Side effects with ACE inhibitors?
generally well tolerated, cough, hyperkalemia, increased SCr, hypotension/dizziness [increased risk if volume-depleted (with concurrent diuretic)], headache
138
What do we monitor for in ACE inhibitors?
blood pressure, K "potassium", renal function, signs and symptoms of angioedema
139
Capoten
captopril - "12.5mg BID - 50mg TID"
140
Avapro *
irbesartan
141
Cozaar *
losartan
142
Benicar *
olmesartan
143
Diovan *
valsartan
144
Edarbi
azilsartan
145
Micardis
telmisartan
146
What are some benefits with ARBs over ACE inhibitors?
Less cough
Less angioedema
No washout period required with Entresto
147
What is an important pearl with azilsartan (Edarbi)?
Keep in original container to protect from light and moisture
148
What Warning does olmesartan (Benicar) have?
sprue-like enteropathy (ongoing damage or irritation and swelling to the small intestine) - severe, chronic diarrhea with substantial weight loss; can occur months to years after drug initiation.
149
Tekturna
aliskiren
150
what class of medications prevents the conversion of angiotensinogen to angiotensin I ?
Direct Renin Inhibitor
ex. Tekturna
151
Contraindications with Tekturna
Do NOT use with ACE inhibitors or ARBs in patients with diabetes
152
Pearls/Notes to know about Tekturna
Avoid high fat foods (reduces absorption)
tablets must be protected from moisture
Take with or without food but be consistent in administration with regard to meals
153
Dosing of Tekturna
150-300mg daily
154
All RAAS inhibitors have increased risk of ________
hyperkalemia. Other medications that increase potassium should be used cautiously. Patients should avoid salt substitutes that contain potassium chloride
155
ACE inhibitors and ARBs should NOT be used in combination with ____________. ACE inhibitors or ARBs are contraindicated with ________ in patients with diabetes
Entresto
Tekturna
156
MOA of Tekturna -
inhibits the conversion of angiotensinogen to angiotensin 1, therefore decreased formation of Angiotensin 1 leading to a decrease in formation of Angiotensin 2.
157
ACE inhibitors and ARBs can ____________ lithium renal clearance and __________ the risk for lithium toxicity
decrease lithium renal clearance
&
increase the risk for lithium toxicity
158
Potassium-sparing diuretics _________ and ___________ have minimal blood pressure lowering effects. They are often used in combination with HCTZ to ___________ seen with thiazide diuretics.
triamterene
amiloride
counteract the mild potassium losses
159
The aldosterone receptor antagonists _________ and ___________ are the preferred add-on drugs in "resistant hypertension" = (uncontrolled blood pressure despite maximum tolerated doses of a CCB + thiazide diuretic + ACE inhibitor or ARB) AND they are commonly used in ________
spironolactone and eplerenone
heart failure
160
which aldosterone receptor antagonist is nonselective and which one is selective?
spironolactone = non-selective aldosterone receptor antagonist (also blocks androgen)
eplerenone = selective aldosterone receptor antagonist ( DOES NOT
161
The potassium sparing diuretics compete with aldosterone at receptor sites in the _________ and ___________ of the nephron, increasing excretion of ________ and _______ but conserving potassium
distal convoluted tubule and collecting ducts
Na+ & H2O
162
Aldactone *
spironolactone tablets
163
CaroSpir
spironolactone oral suspension
(approved for HF and edema due to cirrhosis) is not therapeutically equivalent to Aldactone and dosing recommendations differ
164
Dyrenium
triamterene
165
Dyazide **
brand D/C triamterene/HCTZ
166
Maxzide *
triamterene/HCTZ
167
amiloride
168
Inspra
eplerenone
169
Eplerenone is a major substrate of ___________; Do NOT USE with ________
CYP3A4
CYP3A4 inhibitors
(ketoconazole, itraconazole, clarithromycin, ritonavir)
170
What are the Boxed Warnings with amiloride & triamterene:
hyperkalemia (K>5.5mEq/L) - more likely in patients with diabetes, renal impairment, or elderly patients
171
What are the Contraindications with Aldactone
Do NOT Use if hyperkalemia, severe renal impairment, Addison's disease
172
What are the Contraindications with Inspra
Do NOT Use if patient taking strong CYP3A4 inhibitors
173
What are the side effects seen with Aldactone
increased K, (hyperkalemia), increased SCr, dizziness
gynecomastia(enlargement of breast tissue in men), breast tenderness, impotence, irregular menses
174
What are the side effects seen with Inspra
increased TG,
increased K (hyperkalemia), increased SCr, dizziness
175
What do we monitor with potassium sparing diuretics?
Blood pressure, K, renal function, fluid status, signs and symptoms of heart failure
176
Potassium Sparing diuretics can _________ lithium renal clearance and __________ the risk of lithium toxicity
decrease
increase
177
Selection of a specific Beta blocker will depend on the _____ being treated.
condition
178
bisoprolol, carvedilol or metoprolol succinate should be used if treating _________
chronic heart failure
179
MOA of Beta blockers:
they decrease BP by competitively blocking beta-1 and/or beta-2 adrenergic receptors, resulting in decreases in HR and myocardial contractility
180
Which beta-blockers have alpha-1 blocking properties
carvedilol & labetalol
181
Beta-blockers with (ISA) ____________ include: ______
intrinsic sympathomimetic activity
acebutolol, penbutolol, pindolol
182
Beta-blockers with ISA are NOT recommended in patients __________. They Do Not _________ heart rate to the same degree as beta-blockers with ISA
post-MI (myocardial infarction)
decrease
183
If a beta-blocker is needed in a patient with bronchospastic disease (asthma, COPD) a ______________ agent is preferred
beta-1 selective
184
Tenormin *
atenolol ------------------- beta-1 selective
185
Brevibloc *
esmolol ------------beta-1 selective
injection
186
Lopressor *
metoprolol tartrate -------------beta-1 selective
tablet, injection
187
Toprol XL *
metoprolol succinate ----------- beta-1 selective
tablet
188
Kapspargo Sprinkle
metoprolol succinate ----------beta-1 selective
capsule sprinkle
189
Betoptic S
betaxolol ----- beta-1 selective ophthalmic solution
also available as a tablet
190
Remember "AMEBBA" for Beta-1 selective beta blockers
atenolol
metoprolol
esmolol
bisoprolol
betaxolol
acebutolol
191
What is the beta blocker that is Beta-1 selective with Nitric Oxide-Dependent Vasodilation
Bystolic ----- nebivolol
192
What are the Non-selective beta-blockers?
Inderal --------- propranolol
Corgard--------- nadolol
pindolol
timolol
Coreg --------- carvedilol
labetalol
193
Inderal LA
propranolol --------- non-selective beta-blocker
Dosing: 80-160mg daily MAX: 640mg daily
194
Inderal XL
propranolol -------- non-selective beta-blocker
dosing: 80mg daily MAX 120mg daily
195
Corgard
nadolol ------------ non-selective beta-blocker
dosing: 40-320mg daily
196
Trandate *
labetalol
197
Normodyne *
labetalol
198
Coreg *
carvedilol IR
199
What are the Boxed Warnings with Beta-Blockers
Do NOT discontinue abruptly (particularly in patients with CAD/IHD); gradually taper dose over 1-2 weeks to avoid acute tachycardia, hypertension, and/or ischemia
200
What are the Contraindications with Beta-1 selective blockers
severe bradycardia; 2nd or 3rd degree AV block or sick sinus syndrome (unless a permanent pacemaker is in place); overt cardiac failure or cardiogenic shock
esmolol- pulmonary hypertension; use of IV non-DHP CCBs
201
What are the Warnings with beta-blockers
Use Caution in patients with diabetes: can worsen hyperglycemia or hypoglycemia and mask hypoglycemic symptoms.
Use Caution with bronchospastic diseases (asthma, COPD), beta-1 selective preferred
Use Caution with Raynaud's/ other peripheral vascular diseases, pheochromocytoma and heart failure (slow dose titration required if used in these conditions)
Can mask signs of hyperthyroidism (tachycardia), can worsen CNS depression
202
Side effects with beta-blockers
bradycardia, fatigue, hypotension, dizziness, depression, impotence (less than thiazides),
cold extremities (can exacerbate Raynaud's)
203
Monitoring with beta blockers
Heart Rate, BP
(decrease dose if HR < 55 BPM)
204
Notes/Pearls with Beta blockers
oral drugs: titrate doses every 1-2 weeks (as tolerated), take without regard to meals (EXCEPT for Lopressor & Toprol XL, SHOULD be taken with or immediately following food)
205
What is the IV:PO ratio for metoprolol tartrate
1:2.5
206
When switching from metoprolol tartrate to metoprolol succinate, the TDD _____________
is the same and should be used
207
Notes/Pearls with Non-Selective Beta blockers
are used in portal hypertension
208
Notes/Pearls with the non-selective beta blocker propranolol
Has high lipid solubility (lipophilic) and crosses the blood-brain barrier; it is associated with more CNS side effects, but this makes it useful for other conditions (migraine prophylaxis, essential tremor)
209
what is the conversion ratio going from carvedilol CR to carvedilol IR
Coreg CR 10mg daily = Coreg 3.125mg BID
Dose conversions ARE NOT 1:1
210
Notes/Pearls with carvedilol
Take ALL forms of carvedilol with food to decrease the rate of absorption and the risk of orthostatic hypertension
Coreg CR 10mg daily = Coreg 3.125mg BID
Dose conversions ARE NOT 1:1
211
Contraindications with carvedilol
Severe hepatic impairment
severe bradycardia; 2nd or 3rd degree AV block or sick sinus syndrome (unless a permanent pacemaker is in place); overt cardiac failure or cardiogenic shock
212
Warnings with carvedilol
Intraoperative floppy iris syndrome has occurred in cataract surgery patients who were on or were previously treated with an alpha-1 blocker
213
which beta blockers are nonselective and are alpha-1 blockers
carvedilol
labetalol
214
which beta blocker is the drug of choice in pregnancy
labetalol
injection is commonly used in the hospital setting and can be administered by repeated IV push or slow continuous infusion
215
Hemangeol
propranolol oral solution
group 2 antiarrhythmic
216
Timoptic
timolol -------------- non-selective beta-blocker
217
Beta Blocker Drug Interactions
Beta blockers can enhance the _______________ effects of insulin and sulfonylureas AND ______ some of the symptoms of _________(shakiness, palpitations, anxiety) symptoms of sweating and hunger are not masked.
hypoglycemic
mask
hypoglycemia
218
Beta Blocker Drug Interactions
beta blockers can _________ insulin secretion, causing _________.
decrease
hyperglycemia
219
Beta Blocker Drug Interactions
Use CAUTION when administering other drugs that decrease HR including _______________________
diltiazem, verapamil, digoxin, clonidine, amiodarone and dexmedetomidine (Precedex)
220
which beta blockers are major substrates for CYP2D6
carvedilol, propranolol, and metoprolol
221
which beta blockers are inhibitors of P-gp and can increase the serum concentrations of P-gp substrates like (cyclosporine, dabigatran, digoxin, ranolazine)
carvedilol & propranolol
222
Contraindications with Bystolic (_________)
nebivolol
Severe Liver impairment ( Child-Pugh > class B)
223
Catapres **
clonidine
dosing: 0.1-0.2mg PO BID. Max dose is 2.4mg daily
centrally-acting alpha-2 adrenergic agonists
commonly used for resistant hypertension
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Catapres-TTS *
clonidine transdermal patch
centrally-acting alpha-2 adrenergic agonists
indicated for resistant hypertension
TTS-1 = 0.1mg/24hr
TTS-2 = 0.2mg/24hr
TTS-3 = 0.3mg/24hr
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Tenex *
guanfacine IR
dosing: 1-2mg QHS
centrally-acting alpha-2 adrenergic agonists
Indicated for resistant hypertension
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Intuniv *
guanfacine ER
centrally-acting alpha-2 adrenergic agonists
Indicated for ADHD
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which medications are centrally-acting alpha-2 adrenergic agonists
clonidine
guanfacine
methyldopa
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Apresoline *
hydralazine
vasodilator
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Kapvay *
clonidine
centrally-acting alpha-2 adrenergic agonists
Indicated for ADHD
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Aldomet
methyldopa
centrally-acting alpha-2 adrenergic agonists
indicated for hypertension
*preferred drug in pregnancy*
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MOA of clonidine, guanfacine, and methyldopa
decrease blood pressure by stimulating alpha-2 adrenergic receptors in the brain and reducing sympathetic outflow of norepinephrine, which decreases SVR and HR
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clonidine is commonly used for ________ and in patients who CAN NOT swallow since it is available as a patch formulation. Patch is changed ______ , it can help with adherence.
resistant hypertension
weekly
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Contraindications with Methyldopa:
concurrent use with MAO inhibitors
active liver disease
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Warnings with Centrally acting alpha-2 adrenergic agonists
DO NOT DISCONTINUE abruptly ( can cause rebound hypertension, sweating, anxiety, tremors) Must taper gradually over 2-4 days
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Warnings with Methyldopa
risk for hemolytic anemia (detected by a positive Coombs test), hepatic necrosis
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Side Effects with centrally acting alpha 2 adrenergic agonists
dry mouth, somnolence, fatigue, dizziness, constipation, decrease HR, hypotension, impotence
headache, depression, behavioral changes ( irritability, confusion, anxiety, nightmares)
clonidine patch: skin rash, pruritus, erythema
methyldopa: hypersensitivity reactions (drug-induced lupus erythematosus (DILE)), edema or weight gain (control w/ diuretics), increase prolactin levels
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Notes/pearls with Catapres-TTS
remove before MRI
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Apresoline *
hydralazine
direct vasodilator
Dosing: PO 10-50mg QID
MAX dose 300mg daily
IM, IV: 10-20mg Q 4-6H PRN
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Rogaine for Men or Women
minoxidil
-OTC topical for hair growth
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minoxidil
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MOA of hydralazine
causes direct vasodilation of arterioles, with little effect on veins. The result is a decrease in SVR and reduction in BP
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MOA of minoxidil
causes direct vasodilation of arterioles, with little effect on veins. The result is a decrease in SVR and reduction in BP
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Blood Pressure = __________ x ___________
(SVR) systemic vascular resistance x (CO) cardiac output
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Cardiac Output (CO) = __________ x ________
stroke (Blood) volume x Heart Rate (HR)
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MOA of alpha-blockers =
bind to alpha-1 adrenergic receptors, which results in peripheral vasodilation of arterioles and veins. NOT RECOMMENDED for hypertension but may be used in men who have (BPH) benign prostatic hyperplasia
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drugs that are alpha blockers -
doxazosin, prazosin, terazosin
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Hypertensive crisis is defined as ______
rapidly accelerating blood pressure (generally >= 180/120)
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What are the two types of hypertensive crisis:
1) hypertensive emergency = rapidly accelerating blood pressure WITH acute target ORGAN DAMAGE that may be life threatening (encephalopathy, stroke, acute kidney injury, acute coronary syndrome)
2) hypertensive urgency - no evidence of acute target organ damage
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Treatment of Hypertensive Emergency:
Treat with IV medications
Decrease Blood Pressure by no more than 25% within the first hour, then if stable, decrease to ~160/100 mmHg in the next 2-6 hours
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Treatment of Hypertensive Urgency:
Treat with any oral medications that has a short onset of action (15-30min)
Decrease Blood pressure gradually over 24-48 hours
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What are some of the KEY IV hypertensive medications for Hypertensive Emergency?
Labetalol Nicardipine Metoprolol tartrate
Diltiazem Verapamil
Hydralazine Propranolol
Chlorothiazide Clevidipine
Nitroglycerin Nitroprusside
Enalaprilat Esmolol
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All Hypertensive products:
Can cause Orthostasis ( a decrease in blood pressure that happens soon after standing or sitting up)
check your blood pressure regularly
Take blood pressure medications as directed, even if you feel well. Lowering blood pressure helps decrease risk of complications such as heart disease, kidney disease and stroke.
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Thiazide-Type diuretics Counseling/Key points
Take this medication early in the day ( no later than 4pm) to avoid getting up at night to go to the bathroom.
Can cause:
-Hyperglycemia
-Photosensitivity
-Sexual dysfunction
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Calcium Channel Blockers Counseling/Key points
Can cause:
-peripheral edema
-gingival hyperplasia
Adalat CC: take on an empty stomach
ghost tablet in the stool (Adalat CC and Procardia XL)
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ACE inhibitors, ARBs, Aliskiren Counseling/Key points
Avoid in pregnancy (teratogenic)
Allergy/anaphylaxis (angioedema)
Ace inhibitors: dry, hacking cough
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Beta-blockers Counseling/Key points
DO NOT discontinue abruptly without consulting your healthcare provider
This medication can mask symptoms of low blood sugar. If you have diabetes, check blood sugar if you notice sweating or hunger.
Can cause sexual dysfunction.
Coreg/Coreg CR - take with food
Lopressor/Toprol XL - take with food or immediately after meals
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Counseling/Key points for Clonidine
Do NOT discontinue without consulting your healthcare provider
patch: apply weekly to upper outer arm or chest The white adhesive cover can be applied over the patch to keep it in place. Remove before an MRI
can cause sexual dysfunction
